December 29, 2023 | By Laidy Diana Martinez CPC, CPB, CPMA, CGSC, CGIC, CASCC
January 2024 Marks the Arrival of G2211: A Three-Year Wait Ends but raises questions of simplicity versus complexity. Though G2211 isn’t a new concept, it has been on hold due to congressional decisions for the past three years.
Finally, in January 2024, this Medicare add-on code is set to be implemented, marking the end of a prolonged wait of anticipation and opening a new chapter for primary care reimbursement. However, this code does not come without its complexities. Professionals across the healthcare spectrum are in pursuit of detailed guidance from CMS on the application of this code, with particular focus on the eligibility criteria for reporting it.
As medical coders grasp Medicare’s definition of G2211 is grasp Medicare’s definition of G2211is, G2211 is crucial for accurate application to provide continuing, complex patient care.
HCPCS code G2211 (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, or complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established).
The Complexities Surrounding Implementation:
- Lack of Detailed Guidance: Since the final rule’s release, healthcare professionals have voiced concerns about the absence of clear, comprehensive guidance on G2211. Many questions remain unanswered, creating uncertainty about its practical implementation, reimbursement implications, and impact on patient care.
- Eligibility Criteria: A critical area of concern is the eligibility criteria for reporting G2211. It is essential to define which conditions qualify as “serious” or “complex” and how these determinations will be made. CMS’s response regarding the absence of specific definitions leaves healthcare professionals seeking clarity.
- Specialty Reporting: Another unresolved issue pertains to which medical specialties will be eligible to report this code. While primary care is a clear candidate, some specialties deal with complex treatments and ongoing care. CMS has not provided a definitive list, further contributing to uncertainty.
Terry Fletcher recently raised crucial questions on a podcast with Sean Weiss, including the lack of CMS addressing many clear issues in the final rule, leaving healthcare professionals without clear protocol. Examples of these included:
- Who decides which condition is serious, and what are the criteria?
- CMS’s response indicates a lack of defined descriptions for “serious” conditions but offers examples of when not to use the code.
- What happens when two different providers from different specialties bill this code on the same date of service?
Note CMS has specified certain restrictions on reporting G2211, however, further guidance is lacking. These restrictions include:
– Not reporting when using modifier 25.
– Not reporting for Method II CAH on the same encounter for TOB 85X.
From my perspective, the most advisable course of action is to implement policies designed to protect your practice from the risk of excessive code usage. It is wise to exercise patience and monitor whether CMS offers additional guidance, as numerous experts warn that premature reliance on this code could lead to more denials than successful payments. Staying well-informed and regularly reviewing the guidelines is essential.
Sources:
https://www.cms.gov/files/document/mm13272-edits-prevent-payment-g2211-office/outpatient-evaluation-and-management-visit-and-modifier.pdf
https://podcasters.spotify.com/pod/show/sean-weiss/episodes/Season-6—Episode-48—TerryTuesday—G2211-Add-on-Code-e2crm0r
Next Steps for Success:
- Review CMS information on G2211
- Create a policy on ill-defined areas of this policy to ensure uniformity in your organization.
- Contact NAMAS for any questions on interpretation or assistance for your organization.
