As of Jan. 1, 2024, Medicare will reimburse the office/outpatient (O/O) evaluation and management (E/M) visit inherent complexity add-on HCPCS code G2211, for primary and other similar longitudinal care for serious or complex conditions. HCPCS code G2211 is fully described as follows:
Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established).
When Can I Use G2211?
HCPCS code G2211 may only be used in conjunction with O/O E/M codes. If this criterion is met, allergists must then assess the nature of their professional relationship with a patient to determine if the use of G2211 is appropriate. Ultimately, allergists who bill G2211 are expected to render ongoing, longitudinal care for that patient. Allergists must determine whether the allergist can reasonably expect to form an ongoing professional relationship with the patient and whether billing G2211 is needed to reflect the time, intensity, and resources associated with that patient’s ongoing care. The care rendered must reflect continuity over time and consistency. The code is aimed at compensating physicians for the trust-building that must occur in an ongoing professional relationship between patient and provider, and the weighing a provider must do in communicating health information to preserve the relationship.
Allergists may only bill HCPCS code G2211 if they intend to assume, or have already assumed and plan to continue assuming, responsibility for the ongoing medical care of a patient. While such longitudinal care will often arise in the context of treating a single, complex or ongoing condition, it may also occur in other contexts. An allergist may demonstrate this type of longitudinal relationship with a patient in either of two ways:
- Allergists may bill HCPCS code G2211 if they are managing the ongoing care for a patient’s complex or serious disease or condition. Allergists who treat conditions requiring multiple visits or an ongoing treatment plan for a single, complex or serious condition may appropriately bill HCPCS code G2211.
- Allergists may bill HCPCS code G2211 if they are the continuing focal point for all needed patient services.
When Should I Not Bill G2211?
CMS has yet to publish clear guidance on when exactly G2211 can be reported. However, based on the guidance that is currently published, it is clear that allergists should not bill HCPCS code G2211 if they do not expect to form – or continue to engage in – an ongoing, longitudinal relationship with a patient. For instance, allergists may not report G2211 for an isolated consultation related to seasonal allergies. Additionally, billing G2211 would be inappropriate if an allergist has had a longitudinal relationship with a patient in the past but does not expect – for any reason – to continue that relationship going forward.
The complexity that G2211 intends to capture is not inherent in the clinical condition itself, but rather the burden and complexity that accompanies ongoing care for a patient. Consider a patient with a condition such as asthma, for instance. Whether an allergist may bill G2211 for that patient’s treatment depends entirely on whether the allergist plans to continue being the focal point of care for either that patient’s asthma or for all needed patient services. Whether the asthma is complex or well-managed at that point does not matter.
In addition, HCPCS code G2211 cannot be billed in conjunction with modifier 25. Modifier 25 is defined as a significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of a procedure or other service. Because spirometry codes must be billed with a “25” modifier, allergists will have to choose between using a spirometry code or the new G2211 code as an add-on to O/O E/M codes. Notably, the reimbursement amounts for spirometry codes 94010 and 94060 (CMS national rates of $26.85 and $38.31, respectively) are higher than the reimbursement rate for G2211 (national rate of $16.05). Thus, allergists may be better off using the spirometry code in conjunction with O/O E/M visits, where appropriate, rather than G2211.
Keep in mind, however, that G2211 can be used with telemedicine visits, when appropriate.
Appropriate Documentation for G2211
If you bill G2211, it is important that you document the reason for billing the code. Supporting documentation must demonstrate two elements:
- That it is medically reasonable and necessary for the practitioner to report G2211.
- The independent medical necessity of the O/O E/M visit.
Appropriate supporting documentation could include, but is not limited to:
- Information included in the medical record or claims history, such as diagnoses, or the complexity or seriousness of the condition, that support a particular patient/practitioner combination.
- The practitioner’s assessment and overall plan of care for the visit.
- Other service codes billed.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.