Spring 2024 Issue

New Code Alert: G2211
By Susan Chapman, MA, MFA, PGYT
For The Record
Vol. 36 No. 2 P. 14

What Coders Need to Know About This New Visit Complexity Add-On Code

On January 1, 2024, CMS activated the office and outpatient (O/O) evaluation and management (E/M) visit complexity add-on code, G2211. This HCPCS code helps primary care providers account for greater resources used during O/O E/M visits that can sometimes arise with long-term provider-patient relationships. For instance, CMS recommends using G2211 when patients see their primary care providers for illnesses like sinus infections; it doesn’t account for the infections themselves but rather for the complexity of “the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.”1 Another recommended way this code is to be used is if a physician provides ongoing care for a serious, chronic condition like HIV. CMS is only allowing G2211 to be applied to encounters covered by Medicare, and its use in Medicaid cases is up to individual states to decide.

Modifier 25 and Code G2211
Like many changes in health care, the activation of G2211, and how to use this new code, can cause confusion. For example, code G2211 cannot be used and is not payable when CPT modifier 25, which accounts for a separate incident or procedure, is reported.

According to an American Medical Association issue brief, “CPT modifier 25 is appended to an [E/M] service code on a claim to indicate the code is a significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service. Its use allows two E/M services or a procedure plus an E/M service that are distinctly different but required for the patient’s condition to be appropriately reported and, therefore, appropriately paid.”2 The brief also states that such a separate event has to be accompanied by documentation that meets the criteria for reporting that service. However, that documentation is not specifically defined. Still, it must be available in the patient’s record to demonstrate “the reported E/M service as distinct and separately identifiable.”2 The brief further clarifies that a patient needn’t receive a separate diagnosis for modifier 25 to be used. A patient could see the provider because of a symptom that then results in a procedure.

“Modifier 25 is only used when the evaluation and management code is separately identifiable from the procedure because minor procedures do typically include an E/M service,” according to Shea Lunt, RHIA, CPC, CPMA, PM, director of coding quality and compliance at The Haugen Consulting Group. “If the visit is truly separately identifiable from the procedure, then you can bill both the procedure and the E/M visit, which then requires modifier 25. It essentially unbundles the procedure from the visit and makes them both separately payable. What CMS is saying with this new code is that when you have an E/M visit that’s billed with modifier 25, you’re not also allowed to use G2211.”

“There’s always been quite a bit of scrutiny around modifier 25,” adds Leonta “Lee” Williams, AAPC’s senior director of education. “A provider bills modifier 25 when they are billing an office visit charge on the same day the patient is receiving some type of treatment. We can think about a patient who is coming in for chemotherapy. The provider oftentimes is going to examine the patient to make sure they’re OK to proceed with the chemotherapy. In that case, that evaluation is considered bundled into that procedure, so the provider isn’t able to bill separately for that office visit. The office visit has to be for something significant or separate from the procedure. But let’s say that same chemotherapy patient also has hypertension and elevated blood pressure. The provider addresses the patient’s blood pressure and makes a change to the medication or provides a refill. In that case, they can bill the office visit with modifier 25 because they’ve addressed a problem separate from the cancer that warrants the chemotherapy. In that way, modifier 25 is triggered because a person is coming in for a treatment and needs an evaluation separate from the treatment that was originally scheduled. Conversely, the use of the new code, G2211, gets triggered by a visit that primarily focuses on the management of a serious or complex condition independent of any procedure.

The New Code vs Raising Reimbursement Rates
A recent CMS Medicare Learning Network (MLN) document on code G2211 states that “[a]ll medical professionals who can bill [O/O E/M] visits (CPT codes 99202–99205, 99211–99215), regardless of specialty, may use [G2211] with O/O E/M visits of any level.”1 And it stresses that not only physicians but also hospitals, suppliers, and other providers that bill Medicare Administrative Contractors for services to Medicare patients may use the code.

Because of CMS’s explanation and the fact individuals using Medicare often have complex health conditions, one might wonder why reimbursement rates were not raised across the board rather than creating a new procedure code. However, Lunt notes that even though CMS allows for providers other than those offering primary care to use the code, because G2211 is generally meant for primary care providers who have longitudinal relationships with their patients, providers like specialists typically would not use G2211 because they are only doing more episodic care. “They’re not doing the ongoing medical care that a primary care physician does. So, they likely wouldn’t use G2211 unless they are doing the ongoing medical care related to the patient’s single serious condition,” Lunt says. “It’s not that a specialist couldn’t use the code, but they would have more visits that don’t meet the criteria than primary care providers would. Raising reimbursement rates, then, would not allow differentiation between those two different care relationships and what happens during those visits.”

Williams emphasizes that CMS has not dictated any specific limitations or exceptions about who can bill with this new code. “As it states in the MLN, the code can be billed by the primary care physician and by specialists, but I do think it’s going to depend on the specialist,” she explains. “Someone recently asked me a question about routine foot care and would that qualify. Maybe not if the provider is only responsible for a portion of a patient’s care. As an example, if a patient has diabetes and they go to their podiatrist for routine foot care, maybe to have their nails cut to make sure that they don’t injure themselves, that’s not a provider who is actually taking care of the diabetes itself. In that instance, the podiatrist may not be able to bill with that code. I think from a specialty perspective, looking at chronic conditions that fall under that specialist’s care management services, identifying those diagnoses and things that they’re only managing a portion of, they don’t have management responsibilities on the patient’s overall care. That is where using the code can get a little tricky.”

Williams also acknowledges that such nuanced distinctions can create documentation challenges for providers. “Different codes require different types of documentation, which can add a burden on the provider,” she says. “Because G2211 is so new, education is just in the beginning stages. Providers need to know what documentation they will need to support their billing. The MLN that was issued in the early part of January 2024 did address some of the concerns voiced by stakeholders. What it said is while Medicare isn’t asking for any additional documentation, the focus is still on that provider’s having a longitudinal relationship with, taking care of, the patient with that single serious or complex condition. The documentation just needs to show that CMS also held a stakeholder call that fielded questions regarding the code, and they noted that an FAQ would be issued to help alleviate any ongoing confusion and concerns.”

CMS anticipates that 38% of providers will use the new code, and while G2211 is intended for O/O E/M visits between providers and patients with ongoing relationships, new patient visits may also be eligible for its use. “CMS does allow for a service during a new patient visit, but you haven’t established that longstanding relationship yet. On the stakeholder call, CMS said the provider’s intent to establish that long-term relationship on the new visit would justify billing with the code,” Williams says. “At the same time, they’re looking for documentation of that type of relationship. One question is what happens if the patient never comes back. If they continue, then everything will be fine. But if they don’t return and there is an audit that goes back 12 months, then the auditors will only see the one visit. Providers have to wonder what that means. Will the money be taken back? We’re hoping that we’ll get answers for those types of questions soon. In the meantime, providers just need to be very careful as to how they use this code.”

Verification of Correct Usage
Verifying that G2211 is used correctly could present additional challenges. “CMS says that they’re going to use claims data to verify correct use of G2211,” Williams explains. “They’re mainly looking at that diagnosis code and the O/O E/M service bill so they’re going to make sure that there was an office visit. The O/O E/M service should be billed from the code range 99202 through 99215, and they’re going to look at the diagnosis that was submitted on the claim. Someone like me, who has been in the industry for a while, we’re going to look to make sure that the providers are truly addressing and billing out chronic services correctly, things like diabetes, hypertension, cancer, and rheumatoid arthritis, as opposed to a common cold. The latter will be a quick way for a claim to be denied because something like a cold is an acute condition. So, they’re going to look at the claims data, and then they’re going to look at the medical records.”

Lunt agrees. “The visit documentation needs to be clear about the reason for the visit and the medical decision-making that was done. The CMS MLN document does say that they may use the medical-record documentation. Therefore, I would expect to see in the documentation not only the assessment and plan for that specific visit, but some information in the medical chart like a plan that indicates the ongoing relationship between the provider and the patient, for instance, follow-up visits that need to be scheduled. There has to be evidence of some history that can be easily inferred from the visit documentation.”

The recent CMS MLN on the use of G2211 offers guidelines on proper documentation, noting that the reason for the O/O E/M visit must be documented and that the visit must be medically necessary and reasonable, but, as Williams notes, no additional documentation is required. It also states, as both experts have emphasized, the documentation could be used “to confirm the medical necessity of the visit and accuracy of the documentation of the time you spent.”1 The MLN goes on to suggest what documentation could be used as support, such as information in the medical record or the claims history, the assessment and plan, and other codes that have been billed.

Education
Williams and Lunt agree that along with the MLN, stakeholder call, and forthcoming FAQ, other forms of provider education could help clarify any confusion that accompanies use of code G2211.

“There could be some risk that G2211 will be overused. So, provider education on the intent of the code is going to be important, and that training is up to each organization and facility,” Lunt explains. “One thing that has to be clear is that just because you’re a primary care practitioner, it doesn’t mean that you would use G2211 on every visit because you don’t necessarily have that required longitudinal relationship with every patient. I think any education has to underscore this important aspect of using the new code. The ongoing relationship is critical to using G2211 correctly.”

“In the beginning, I think providers are going to help educate Medicare on what is and is not appropriate,” Williams adds. “Without any clear definitions or guidance, it seems like it has to be up to the providers to define this service, at least right now. As time goes on, hopefully, it will shift and be the other way around.”

— Susan Chapman, MA, MFA, PGYT, is a Los Angeles–based freelance writer and editor.

 

References
1. Centers for Medicare and Medicaid Services. How to use the office & outpatient evaluation and management visit complexity add-on code G2211. https://www.cms.gov/files/document/mm13473-how-use-office-and-outpatient-evaluation-and-management-visit-complexity-add-code-g2211.pdf. Published 2024.

2. American Medical Association. Modifier 25. https://www.ama-assn.org/system/files/issue-brief-cms-modifier-25.pdf. Published 2023.