Your patients receive intricate and all-encompassing treatment from you. You’ll receive payment for it more precisely if you use G2211, use this new add-on CPT code, together with office/outpatient evaluation and management (E/M) codes, starting January 1, 2024, to get paid more for the high-value visits you do.

What is G2211?

Add-on code for the Healthcare Common Procedure Coding System (HCPCS) When doctors provide office/outpatient visits that foster long-term relationships with patients and handle the bulk of a patient’s health care needs consistently and continuously over longer periods of time, G2211 represents the time, intensity, and practice expense resources involved. In order to more accurately account for the resource expenditures related to the visit complexity that is a feature of primary care and other longitudinal care, the Centers for Medicare & Medicaid Services (CMS) developed code G2211.

When and How to Use CPT Code G2211?

In mid-January, CMS published a brief article with instructions on how to utilize CPT code G2211. Among the particular billing specifications are:

• G2211 (99202-99215 alone) needs to be billed with an office or outpatient E/M code.
• G2211 is not appropriate for usage in skilled nursing or inpatient hospital settings.
• When the E/M code is billed with modifier 25, G2211 cannot be billed.
• Acute treatment cannot be provided with G2211.

Medicare’s definition of a “single, serious condition or a complex condition” as it relates to the use of this code is not well-defined. The code should be used, according to instructions in their most recent Medicare Learning Matters post, if:

• You serve as the ongoing hub for all necessary services, much like a primary care physician.
• You’re providing continuing care for a single, severe ailment or a complex one, such as HIV or sickle cell illness.

Which clinical scenarios call for the use of G2211 in complex or dangerous cases requiring long-term, longitudinal care?

• Care for Head and Neck Cancer.
• Airway disorders in children.
• Management of Refractory Chronic Sinusitis.
• Care for Skull Base Tumors.
• Reconstruction of the Face.
• Voice Issues.
• Handling Sleep Apnea.
• Congenital anomalies in children.
• Palate and Cleft Lip Care.
• Chronic Disorders of the Salivary Gland.
• Children’s Hearing Loss.
• Adult Complex Hearing Loss.
• Disorders of the Thyroid and Parathyroid.
• Refractory Vertigo and Dizziness Syndromes.
• Continuous Management of Complex Rhinitis, such as Immunotherapy.
• Difficult Swallowing Conditions.
• Laryngopharyngeal reflux that is refractory (LPR).
• Discrete Epistaxis.
• Otomastoiditis cronica.
• persistent brain neuropathies.
• persistent, complex voice disorders.
• Headaches.

Documentation guidelines:

For the practitioner to record this add-on code, the visit must be medically necessary and reasonable, and the justification for utilizing CPT code G2211 for the visit must be documented. As a result, the documentation must unambiguously demonstrate the visit’s medical need.

According to CMS, medical reviewers may utilize the material from the medical records to verify the visit’s medical necessity and the accuracy of the visit’s time log. The following things could be used as billing CPT code G2211 supporting documentation:

• Details such as diagnoses that are contained in the medical record or the claim history for a patient/practitioner pair.
• The visitation schedule and the practitioner’s evaluation.
• Additional service codes that were billed.

How to Start Billing for G2211:

• Make sure your’ s billing and/or EHR systems are up to date with the Medicare physician fee schedule for 2024.
• Make sure that G2211 has been included in the updates. Billing and coding personnel or practice management personnel can typically assist with this.
• Tell them that there can be an additional charge on their statement because of the application of coinsurance and deductible.
• When attending an office visit when you have taken over or plan to take over the patient’s continued medical care, report the HCPCS code G2211.
• If modifier 25 is used to report the office visit, G2211 is not due.
•  Inform your coding team and administration about the significance of G2211. 

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Inform them that:

• Research indicates that office visits by primary care physicians are more involved than those by other specialists. By managing all of a patient’s acute and chronic diseases, offering continuing preventative services, counseling, and attending to behavioral health issues and unmet social requirements, primary care physicians condense extremely complicated care into quick visits. CPT code G2211 is required in order to properly account for this extra complexity and the associated practice costs.
• Medicare authorities concur that the more complicated, whole-person care that primary care physicians offer is not adequately accounted for by the new office visit E/M payments. Current coding systems perform better at identifying procedures than they do at characterizing cognitive services, such ongoing, all-inclusive primary care.
• Many of the special services and resources that primary care doctors offer are not taken into consideration by the current E/M coding, nor does it adequately recognize their exceptional role in patient care coordination.

G2211 modifications suggested for 2025:

CMS published its PFS proposed rule on July 13, 2025, and primary care will benefit from the adjustment. In the event that the agreement is approved, beginning on 1-1-2025, claims with modifier 25 will be paid where the extra service rendered is an annual wellness visit, the administration of a vaccination, or any other CMS-covered preventive medicine care.