On December 1, 2020, the Centers for Medicare and Medicaid Services (CMS) released its Medicare Physician Fee Schedule (PFS) final rule, which takes effect on January 1, 2021. Download the spreadsheet of new relative value units and reimbursement for services commonly provided by allergists.
New for 2021 is a complexity add-on code, HCPCS G2211, which can be used with certain office/outpatient E/Ms. CMS also added this code to the Medicare telehealth services list for 2021. HCPCS code G2211 is an add-on code and can be billed separately in addition to new or established patient office/outpatient E/M codes.
It will be reimbursed by Medicare at a national rate of $15.88. However, the Medicare PFS rule only approves this code for Medicare reimbursement, which comprises just 10 – 15% of many allergy practices. It is not clear whether commercial payers will pay for HCPCS code G2211.
The descriptor of HCPCS code G2211 is 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).
CMS intends that use of this code will address the additional time, intensity, and practice expense when physicians provide services that allow them to build longstanding relationships with their patients and to address the majority of the patients’ health care needs with consistency and continuity over long periods of time. It is also intended to address the additional time, intensity and practice expense associated with ongoing care related to a single serious or complex condition. The code is intended for use by primary care and cognitive specialties including, specifically, allergy, but is not likely to be used by surgical specialties or specialties like radiology and pathology. CMS estimates the code would apply to as many as 90% of office visits.
In an effort to provide guidance, CMS has described circumstances under which HCPCS code G2211 would not be appropriately reported, including:
- When the care furnished during the office/outpatient E/M visit is provided by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature (e.g. mole removal).
- For treatment of a simple virus or treatment for a fracture.
- By way of example, for counseling related to seasonal allergies or initial onset gastroesophageal reflux disease.
- Where comorbidities are either not present or not addressed, and/or when the billing practitioner has not taken responsibility for ongoing medical care for that particular patient with consistency and continuity over time, or does not plan to take responsibility for subsequent, ongoing medical care for that particular patient with consistency and continuity over time.
In addition, CMS does not expect that HCPCS code G2211 would be reported when the office/outpatient E/M is reported with a payment modifier (e.g., modifier 25), although it is not prohibiting that use. CMS stated it will consider whether to establish such a prohibition in future rulemaking. Although CMS has attempted to provide additional guidance on use of this code, this is still likely to be a source of confusion. In particular, allergies, whether seasonal or not, could be a serious condition that requires ongoing care.
The Advocacy Council will continue to monitor and report on developments related to reimbursement of HCPCS code G2211. The Advocacy Council – we have you covered.