G2211 Code: AHS Practice Management Review

January 1, 2024, HCPS add-on code G2211, created by the Center for Medicare and Medicaid Services (CMS), is now payable by CMS.  G2211 may be reported alongside new and established patient office/outpatient evaluation and management (E/M) services.  This may result in an additional 0.33 RVUs, or approximately $16, per use.

Why Is This Important?

CMS recognized there is additional time, intensity, and practice expense resources involved when providing a longitudinal relationship with a patient’s health care needs.  CMS will now provide additional financial support to providers offering these services.

CMS Code Descriptor: 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 condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)

When to Use G2211

• Consider the add-on code when you are the continuing focal point for all health care services the patient needs for a single, serious complex condition.  Per CMS, the relationship between the patient and the physician is the determining factor of when the add-on code should be billed.  

Do not use G2211 when:

• Your relationship with the patient is of a discrete, routine, or time-limited nature. For example, a physician who sees a patient for an acute concern should not report G2211 if they have not also assumed responsibility for the patient’s ongoing medical care or do not plan to take responsibility for subsequent, ongoing medical care with consistency and continuity over time.
• The associated office visit E/M is reported with modifier 25 appended.
• Reporting CPT code 99211.

Additional Tips From the Practice Management Committee:

CMS does not provide guidance for treating headache disorders. Thus, there will be some interpretation in the use of the code, and we request your feedback on the outcome of this code in your practice. Please email your experiences to the AHS Practice Management Committee at AHSHQ@talley.com. 

For headache, some example diagnoses that should warrant the use of G2211 (not all-inclusive): chronic migraine, hemicrania continua, chronic cluster headache, post-traumatic headache, and new daily persistent headache. If an episodic migraine patient is deemed to be complex and a provider provides ongoing care such that the practice sees the patient within a year for ongoing care, G2211 may be appropriate.

• G2211 is not an AMA CPT code.  While Medicare and Medicare Advantage will accept this code, commercial insurers may or may not cover this add on code. Billing a patient whereby the code is non-covered may generate an additional charge for a patient.  Contact your commercial payers to clarify if they will reimburse for G2211. Develop a plan to determine appropriate billing practices if the code is not reimbursed by the payer.
• While not explicit in CMS rule making, the spirit of this code is to reimburse for longitudinal care of a serious or complex condition by the practice. This could include resident clinic patients and advanced practice provider’s patients if there is ongoing care within the practice.
• CMS does not communicate any documentation is required to code G2211. As a result, for auditing purposes, the practice will need to decide if they wish to create documentation to affirm they are providing ongoing care related to a patient's single, serious condition or a complex condition.