Code G2211 – Another Opinion, and Several Questions

Code G2211 – Another Opinion, and Several Questions

It is not a secret that physician payment from Medicare has been declining for years. In the past, physicians faced a yearly crisis in December, as their fees were set to drop by significant amounts due to the Sustainable Growth Rate (SGR) provision of the Social Security Act.

Each year, Congress had to step in and allocate more money for physicians to avoid payment cuts that would have likely led to a significant exodus of physicians from the Medicare program. Finally, in 2015, the SGR provision was repealed.

But the payment updates that replaced the SGR have not kept up with the costs of providing healthcare, and again physicians have been faced with unsustainable payment rates. Perhaps realizing the impending crisis, the Centers for Medicare & Medicaid Services (CMS) in 2021 established HCPCS code G2211, with the long descriptor of “visit complexity inherent to evaluation and management (E&M) 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.”

Alas, the Consolidated Appropriations Act of 2021 imposed a moratorium on Medicare payment for these services by prohibiting CMS from making payment under the Physician Fee Schedule for HCPCS code G2211 before Jan. 1, 2024.

Now that 2024 has arrived, HCPCS code G2211 is finally available for use by physicians when providing care to Medicare beneficiaries. To aid understanding, CMS has published Transmittal 12461, updating Chapter 12 of the Medicare Claims Processing Manual, and MLN Matters 12473, which has abbreviated versions of the case examples provided in the transmittal.

As often happens when a new code is introduced, confusion reigns. Some quotes from social media: “The code recognizes the extra work required to chronically manage complex medical conditions when providing ongoing medical care.” “The collaborative care plan must be documented in the patient medical record.” “HCPCS code G2211 cannot be billed with an office or outpatient E&M visit that is focused on a procedure or other service instead of being focused on longitudinal care for either all needed healthcare services or a single serious or complex condition.”

Many are focused on the description referring to a serious or complex condition. Others are concerned about the documentation to support the relationship to justify billing G2211. Now, with the caveat that I am an individual with no special insider knowledge nor certification in coding, I would offer the following interpretation on the use of G2211.

First, the “don’ts.” Don’t use G2211 if the E&M code will be appended with modifier -25; an edit in the claim processing system will deny payment for G2211. But before you do this, ensure that your billing staff is using -25 correctly and not applying it indiscriminately, such as on X-ray codes. Unfortunately, E&M visits with a vaccine administration requires modifier -25, so G2211 would not be paid. This, of course, makes no sense, since the administration of vaccines is a crucial role of a longitudinal relationship between a patient and their physician, and I have asked CMS to reconsider this exclusion.

And here is the “do.” Do bill G2211 for every other office or other outpatient visit billed with 99202-99215 if the patient has been seen in the past or potentially will be seen in the future for anything other than a time-limited issue.  

For example, say a patient is seen by an orthopedic surgeon for a sore knee. An X-ray demonstrates mild arthritis. The patient is counseled on over-the-counter medications and exercises and offered a referral to physical therapy. A follow-up appointment is made for three months later. Bill G2211 with the appropriate E&M code. Osteoarthritis is a serious condition that often requires surgery. A longitudinal relationship has been established. Of course, there is a chance that the patient will never be seen again. That second visit is not a requirement, as CMS permits G2211 with new patient visits, and no one can guarantee that second visit will occur. But if that second visit does occur, use G2211 on this visit, too.

For established patients, use the code on every visit. That’s right – every visit (…without a -25). As CMS demonstrates in its first case example, the problem that warranted the visit does not in itself have to meet any degree of seriousness, unless you consider “absolutely not serious” a degree of seriousness (in which case that would be acceptable seriousness to use G2211). That CMS example involved a patient presenting with sinus congestion, a condition normally treated with facial tissues and time. And the patient description features no indication that the patient even has any chronic illnesses that would be considered serious, such as diabetes or hypertension. The only qualifying factor is that the patient considers the physician to be “their doctor.” Now, the physician may be recently out of residency and carefully assessing for evidence of mucormycosis, a truly serious sinus infection, but that is unlikely to be the diagnosis. Likewise, a second visit with the practitioner does not need to be for the same “serious” condition. If that patient with arthritis of the knee sees the orthopedist for wrist pain a month later, use G2211. Even if it is a different problem, it is now a longitudinal relationship between the patient and the physician, and to paraphrase CMS, if the orthopedist does not take the wrist pain seriously, the patient may lose confidence in the physician when it comes to treatment of their arthritis.

CMS does provide extensive discussion about when not to use G2211 with 99202-99215, noting that an “add-on code would not be appropriately reported, such as when the care furnished during the office or outpatient E&M visit is provided by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature; such as, but not limited to, a mole removal or referral to a physician for removal of a mole; for treatment of a simple virus; for counseling related to seasonal allergies, initial onset gastroesophageal reflux disease; treatment for a fracture; and 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.”

It is crucial to read this critically, noting CMS’s use of “and” and “or.” What CMS is stating here is that G2211 should not be used for urgent care visits or acute illnesses/injuries where there will be no longitudinal follow-up. Does a patient seeing an internist for the first visit for a simple viral infection warrant G2211? If they are passing through town and a friend recommended their doctor or the patient goes to an urgent care center, then no. But if the patient may return to the same physician for other medical needs in the future, then that physician has taken responsibility for their ongoing medical care, and G2211 is appropriate. A patient with a wrist fracture seen by an orthopedist does not warrant G2211. But what if the patient mentions that they have chronic joint pain and may want that addressed in the future – then, has a longitudinal relationship has been established, whereby G2211 is appropriate to use on this first visit? Although CMS mentions “initial onset gastroesophageal reflux disease” as not warranting G2211, if testing is performed or planned and follow-up is needed, it certainly seems that G2211 is warranted.

Physicians covering for each other raise another “what if?” If the patient has a longitudinal relationship with a physician, but that physician is not available to see the patient for an acute illness, can the covering physician, within the same practice of the same specialty, use G2211? One could argue that this physician must regard the visit as would the primary physician, taking the concerns seriously and not eroding the trust, so G2211 could be used, but CMS has not directly addressed this scenario. But noted healthcare reimbursement attorney Richelle Marting, Esq., and nationally known coding expert Betsy Nicoletti, both of whom I call friends, agree that “physicians in a group of the same specialty bill and get paid as if they were the same physician,” so they both contend that G2211 is appropriate to use.

Likewise, CMS has not discussed the use of G2211 for a subset of patients seen in the hospital. 99202-99215 codes are commonly referred to as office visit codes, and would be billed with place of service 11 or 19, but are also used for physician visits of hospitalized outpatients. Neither the MLN Matters nor the CMS Transmittal make any mention of place of service. For example, consider the Medicare patient who presents to the ED with chest pain and is placed in the hospital as an outpatient with observation services for further testing. The hospitalist will bill their visits with codes 99221-99233, using place of service 22, whereby G2211 is not applicable, but if a cardiologist is consulted, they would bill with 99202-99215, place of service 22 for their visits. If that cardiologist sees the patient on the first day, billing 99204 for their visit, and then the next day, billing 99214, have they established a longitudinal relationship? Is two days too short? Remember, the patient will most likely be given a follow-up appointment with that cardiologist; does that not mean the cardiologist has taken responsibility for that patient’s future cardiac care? It certainly seems that G2211 may be applicable in the hospital setting, under certain circumstances.

Now, the case of hospitalists using G2211 if their visit is to be billed with the outpatient codes 99202-99215 is a bit murkier. This can occur when the hospitalist is consulted to manage the medical issues of a patient having outpatient surgery that involves an overnight stay, as often happens with joint replacement or prostate surgery, among other procedures. Since the hospitalist is not ordering observation services, which is not warranted here, they would use the outpatient visit codes. In this scenario, the patient may be seen twice during the hospital stay, but since a hospitalist’s practice is hospital-based, the patient will not be given an appointment to see the physician after discharge. Unless CMS considers those two visits a longitudinal relationship, G2211 would not be appropriate.

But then again, there are hospitals that, as part of their efforts to reduce avoidable readmissions, have started “continuity clinics” where hospitalists rotate, seeing previously hospitalized patients for a visit or two to ensure that they are on the road to recovery. Falling back on the “physicians in the same group and same specialty” billing rule, would this visit constitute the totality of the care provided to the patient in the hospital and in the clinic being longitudinal, thus qualifying for G2211?

CMS also stated that there needs to be absolutely no documentation to support G2211. If the E&M visit occurs and the visit is documented, that meets the documentation requirement for G2211. There is no need to state anything about the relationship; it is inherent in the encounter that a relationship has been established or continued. If the doctor normally documents considering mucormycosis when evaluating sinus congestion, they should continue that practice, but such detail is not necessary to use G2211.

To quote Betsy Nicoletti, “I am hanging my hat on the claims history” to support the use of G2211. Do not set up a phrase for your doctors that states, “I have thought long and hard about the implications of my medical decisions on my relationship with the patient, and the decisions I have made are in the best interests of the patient’s short-term health and will contribute to building up an effective, trusting longitudinal relationship with this patient for all of their primary health care needs.”

The added payment associated with G2211 is welcomed by office-based physicians to help, in a very small way, reduce some of the payment cuts they have faced in the past. But rather than simply increasing the value of the office visit codes, federal regulation limitations required the development of this separate code, and along with it came the many ambiguities outlined above. CMS has promised further guidance; all of us will be anxiously awaiting it, hoping they provide some clarity.

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Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, and the National Association of Healthcare Revenue Integrity, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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