Effective January 1, 2024 the Centers for Medicare and Medicaid Services (CMS) implemented payment for G2211, a HCPCS add-on code to be billed in conjunction with an office/outpatient evaluation and management (E/M) code in certain instances. When billed, this results in higher payment for the E/M encounter, regardless of level. The national payment rate for G2211 is $16.05.
In August 2024, CMS shared a new Frequently Asked Questions document with additional guidance.
AAPM&R will monitor private payor implementation of G2211. At the time of developing this educational information, it is unclear which private payors, if any, have or will implement coverage of G2211.
Code Origins and Purpose
G2211 was originally proposed in 2021 by CMS to better capture the costs of providing care associated with longitudinal care such as what is provided during a primary care encounter or an encounter by a specialist who cares for a patient over long periods of time. Due to budget neutrality concerns and because of the estimated impact on physician payment, Congress delayed implementation of this conde for several years. 2024 is the first year G2211 can be billed.
G2211 Descriptor – 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).
How and When to Use G2211
CMS released a brief article providing guidance on the use of G2211 in mid-January (see below). Some specific billing requirements include:
- G2211 must be billed alongside an office or outpatient E/M code (99202-99215 only).
- G2211 cannot be used in the inpatient hospital or skilled nursing setting.
- G2211 cannot be billed when the E/M code is billed with modifier 25.
- G2211 cannot be used for acute care.
Medicare has provided limited information about how it is defining “single, serious condition or a complex condition” for the purposes of using this code. Instructions in their recent Medicare Learning Matters article indicate that the code should be used if:
- “You’re the continuing focal point for all needed services, like a primary care practitioner
- You’re giving ongoing care for a single, serious condition or a complex condition, like sickle cell disease or HIV.”
Applications for Physiatry
To-date, CMS educational materials have not directly referenced scenarios for use of G2211 that are applicable to physiatry. However, the code is not restricted to certain specialties. Based on the examples and context provided, there are many conditions known to be serious or complex for which the physiatrist could be the physician managing the patients’ care. As indicated by CMS, “The most important information used to determine whether the add-on code could be billed is the relationship between the practitioner and the patient…The add-on code G2211 captures the inherent complexity of the visit that is derived from the longitudinal nature of the practitioner and patient relationship.”
Next Steps
If, based on this information, G2211 is a code that would fit into your practice and patient population, talk with your practice manager, administration, and coding staff about implementing billing of this code for appropriate patients.