Introduction

Physician reimbursement has historically placed higher value on procedural services and lower value on outpatient office evaluation and management (E/M) services, such as those provided by primary care providers (PCP).1 Relaxation of documentation requirements for E/M visits in 2021 led to increased payments for PCPs, but only a 2% decline in the reimbursement gap between PCPs and proceduralists.2 With the release and implementation of the G2211 code in January 2024, the Centers for Medicare and Medicaid (CMS) provided an additional mechanism for primary care providers and other physicians to receive payment for the work they do every day.3,4

G2211 is an add-on code for outpatient office E/M visits that reimburses clinicians for additional work associated with providing comprehensive, longitudinal, and continuous care to patients with complex condition(s) or a single serious condition. It accounts for aspects of care that are not captured by other billing codes, including developing effective and trusting relationships over time, acting as the “continuing focal point for all needed services,” and understanding how a patient’s medical and/or social history may affect their health today.3,4 CMS estimates that the G2211 code will be used frequently by non-procedural clinicians and much less by surgeons and proceduralists.3,4

As this code is still in the early stages of implementation, questions about its usage are common. This article describes appropriate usage of the G2211 code and provides clinical examples that may arise in a PCP’s daily practice.

What Is the Payment for G2211 and What Insurance Covers It?

The 2024 national Medicare allowable cost for G2211 is $16.04.5 Only Medicare Part B is required to cover G2211. As of March 1, 2024, Cigna, Humana, and United Healthcare Medicare Advantage plans, as well as Humana and United Healthcare commercial plans, also cover the G2211 code.5 Many health systems encourage clinicians to bill this code when appropriate to support its adoption by additional payers.

When Should I Use G2211?

The G2211 code can be used by physicians and advance practice providers (e.g., nurse practitioners and physician assistants) if the following criteria are met:3,4

  1. The billing clinician works within a fee-for-service payment model;
  2. The encounter is an outpatient office E/M visit;
  3. The clinician is not performing a procedure that would entail adding on a 25-Modifier; and
  4. The clinician has established or intends to establish a longitudinal relationship with the patient (“continuing focal point for all needed health care services”) and provides ongoing care of one or more complex condition(s) or a single serious condition.

CMS does not stipulate any restrictions tied to length of clinical encounters, acknowledging that while expert PCPs are able to manage multiple complex problems in a short time, the cognitive load required to do so is high.

How Should I Use G2211?

Clinicians should continue using the same Current Procedural Terminology codes for outpatient office E/M visits. They can then capture G2211 as an add-on code when appropriate. There are no additional documentation requirements beyond describing the care provided for the patient’s chronic conditions and the development or implementation of a care plan. Note that G2211 is meant to specifically reimburse clinicians for their professional work during the clinical encounter, rather than any care management endeavors conducted outside of the encounter, which are billed separately.

When Should I Not Use G2211?

The code should not be used in following situations:3,4

  1. The clinician uses a 25-Modifier on the same day as the clinic visit; the 25-Modifier is used to bill for minor office-based procedures such as suture removals and joint injections;
  2. Acute visits that do not involve management of chronic issues (e.g., specialty consultations, urgent care visits);
  3. Management of conditions that have a limited course (< 3 months) if the clinician does not plan to treat the patient longitudinally;
  4. The billing clinician works in a capitated payment model; and
  5. Medicare Annual Wellness Visits.

CMS chose not to allow use of the G2211 code in conjunction with the 25-Modifier to ensure that the G2211 code would be used primarily by clinicians delivering longitudinal care.3 However, one might envision scenarios in which coding for both G2211 and the 25-Modifier could be appropriate. For example, a PCP might engage in a discussion about diet and lifestyle while simultaneously preparing for and conducting a knee steroid injection. Physicians should use their experiences with similar scenarios to advocate for future adjustments in implementation of the G2211 code.

Clinical Examples

A PCP sees her established patient with hypertension for a walk-in visit, for evaluation of a sore throat. The PCP recommends over-the-counter remedies, counseling to avoid medications that raise blood pressure.

Yes, use G2211 for this condition that has a limited course because the PCP considered the patient’s hypertension when providing recommendations, and hypertension is a chronic condition the PCP manages. The PCP should use the sore throat and hypertension diagnosis codes for this visit.

A patient presents to their PCP for their Medicare Annual Wellness visit. The clinician and patient discuss management of the patient’s diabetes and hypertension.

No, here the Annual Wellness Visit code acts as a 25-Modifier, so the G2211 code is not allowed.

A patient presents to establish care with a new PCP. The patient has hypertension and diabetes.

Yes, the patient has chronic issues that the PCP plans to manage longitudinally.

An endocrinologist sees an established patient for uncontrolled diabetes. She adjusts the patient’s short-acting insulin dose. She then calls the patient’s caregiver to relay the plan and schedules a four-week follow-up visit.

Yes, G2211 is not designed to be specialty-specific; if the code requirements are met, clinicians of any specialty can use it.

A PCP sees an established patient with hypertension and gout who has a knee effusion. He performs an arthrocentesis, adjusts the patient’s antihypertensives, and schedules a follow-up visit.

No, a procedure was performed, and a 25-Modifier will be used; a clinician cannot code for G2211 and the 25-Modifier on the same day.

A resident sees an established patient in follow-up for their diabetes, hypertension, and congestive heart failure. The attending precepts the resident and sees the patient.

Yes, use G2211 as an attending physician precepting in resident clinic; if the attending does not see the patient, it is still ok for them to use G2211 as long as they have permission to use the primary care exception.

A nurse practitioner sees an established patient in follow-up for their diabetes, hypertension, and congestive heart failure.

Yes, nurse practitioners and physician assistants can use G2211 when seeing patients independently.

A PCP sees an established patient in a telehealth visit, during which they discuss the patient’s mental health. The physician recommends starting a new antidepressant.

Yes, use G2211 during telehealth visits when appropriate.

A PCP sees a patient with diabetes who is established with a different clinician in their practice. That clinician is out sick today. The PCP and patient discuss a new diabetic foot ulcer and agree on changes to the patient’s diabetes regimen.

Yes, if the patient has developed a longitudinal relationship with their PCP’s “care team,” then using G2211 is appropriate.

Conclusion

While billing and coding can be cumbersome, G2211 is evidence that CMS is making major efforts to address PCPs’ reimbursement concerns. G2211 is not perfect, but it is a major step towards improving reimbursement to clinicians in the non-procedural specialties that have historically been undervalued.1,2 In particular, this new code could help SGIM members in primary care and non-procedural specialists offset the financial impact of recent Medicare reimbursement cuts, without significantly increasing their administrative burden.

References

  1. Kumetz EA, Goodson JD. The undervaluation of evaluation and management professional services: the lasting impact of current procedural terminology code deficiencies on physician payment. Chest. 2013;144(3):740-745.
  2. Neprash HT, Golberstein E, Ganguli I, et al. Association of evaluation and management payment policy changes with Medicare payment to physicians by specialty. JAMA. 2023;329(8):662-669.
  3. Centers for Medicare & Medicaid Services. Medicare and Medicaid Programs; CY 2024 Payment policies under the Physician Fee Schedule and other changes to Part B payment and coverage policies; Medicare Shared Savings Program requirements; Medicare Advantage; Medicare and Medicaid provider and supplier enrollment policies; and Basic Health Program. https://www.federalregister.gov/documents/2023/11/16/2023-24184/medicare-and-medicaid-programs-cy-2024-payment-policies-under-the-physician-fee-schedule-and-other. Published online November 6, 2023. Accessed May 15, 2024.
  4. Calendar Year (CY) 2024 Medicare Physician Fee Schedule final rule. CMS.gov. https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule. Published November 2, 2023. Accessed May 15, 2024.
  5. G2211 Add-on code: What it is and how to use it. Amer Assn Family Physicians. https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/evaluation-management/G2211-what-it-is-and-how-to-use-it.html. Accessed May 15, 2024.

Issue

Topic

Clinical Practice, SGIM

Author Descriptions

Dr. Syed (Quratulain.syed@va.gov) is a geriatrician at Joseph Maxwell Cleland VA Medical Center in Atlanta, GA. Dr. Newby (cnewby@tulane.edu) is an assistant clinical professor of medicine at Tulane University School of Medicine. Dr. Sloan (caroline.sloan@duke.edu) is an assistant professor of medicine at Duke University School of Medicine.

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