Do you offer longitudinal care or value-based care to your patients? If so, your medical practice may be eligible to bill Medicare and Medicaid add-on code G2211 per the CPT 2024 guidelines.
Yes, you heard it right; as per CMS, providers that become the focal point for the ongoing health care services a patient needs can bill G2211 along with their patient office/outpatient (O/O) evaluation and management (E/M) services. The O/O E/M services CPT codes are 99202-99205, 99211-99215.
The billing of G2211 is determined by the ongoing nature of care and not by the complexity of clinical conditions. Additionally, the add-on code G2211 can be used by practices across medical specialties. The 2024 national Medicare allowable rate for G2211 is $ 16.05
However, there are three caveats for billing G2211 across specialties. These are as follows:
- Proper documentation: Firstly, you must document the reason for billing the O/O E/M visit. The supporting documentation must include the patient’s medical history, the provider’s assessment, the treatment plan, and the other service codes billed.
- Routine/ad-hoc visits excluded: The second caveat is that you cannot bill G2211 if you have not assumed responsibility for the patient’s ongoing medical care or if the interaction with the patient is for a routine visit. Submit HCPCS code G2211 for office visits only if you have taken on or plan to be responsible for the patient’s continuous medical management.
- Modifier -25 excluded: Thirdly, code G2211 is not payable when the office visit is reported with modifier 25. The CMS payment will be as per the physician’s fee schedule. Since G2211 is subject to Medicare’s deductible and coinsurance, please do inform your patients before you start billing them. As of now, private payers are not required to cover G2211 separately.
G2211 is on the Medicare List of Telehealth Services and can be billed with office visit E/M (CPT codes 99202-99215) services provided via telehealth.
PracticeForces VP Holly Vogt, CPC, CPPM, CCAT, breaks down the guidelines for using add-on code G2211.
Here are two case scenarios provided by CMS where G2211 can be billed:
Example 1: A patient sees you, their primary care practitioner, for sinus congestion. You may suggest conservative treatment or antibiotics for a sinus infection. You decide on the course of action and the best way to communicate the recommendations to the patient in the visit. How the recommendations are communicated is important in that it not only affects the patient’s
health outcomes for this visit, but it also can help build an effective and trusting longitudinal relationship between you and the patient. This is key so you can continue to help them meet their primary healthcare needs.
The complexity that code G2211 captures isn’t in the clinical condition – the sinus congestion. The complexity is in the cognitive load of the continued responsibility of being the focal point for all needed services for this patient. There’s an important cognitive effort of using the longitudinal doctor-patient relationship itself in the diagnosis and treatment plan. These factors, even for a simple condition like sinus congestion, make the entire interaction inherently complex. In this example, you may bill G2211.
Example 2: A patient with HIV has an office visit with you, their infectious disease physician. The patient tells you they’ve missed several doses of HIV medication in the last month because you’re part of their ongoing care and have earned their trust over time. You tell them it’s important not to miss doses of HIV medication while making the patient feel safe and comfortable sharing information like this with you in the future.
If you didn’t have this ongoing relationship with the patient and the patient didn’t share this with you, you may have decided to change their HIV medicine to another with greater side effects, even when there was no issue with the original medication. Because you’re part of ongoing care for a single, serious condition or a complex condition such as HIV and have to weigh these types of factors, the E/M visit is more complex. In this example, you may bill G2211.
As of now, private payers are not required to cover G2211 separately, but we encourage you to speak to your payers during contract negotiations to include G2211 as part of your fee schedule.
If you have any questions on G2211 or any other CPT 2024 code changes, please contact us at questions@practiceforces.com or submit your query by visiting our website.
