Enhanced payment to support longitudinal care: The new E/M complexity add-on code G2211

Patient-centered, whole-person care and the development of longitudinal patient-physician relationships are central to the practice of osteopathic medicine. Establishing trust with patients, understanding their needs and concerns, and building relationships can require significant time and effort. In recognition of the complexity inherent to this work in evaluation and management (E/M) services, the Centers for Medicare & Medicaid Services (CMS) has established a new E/M add-on code to support appropriate payment.

This article answers common questions regarding the new G2211 add-on code. For additional details regarding this code and the array of changes in the CY2024 Medicare Physician Fee Schedule, view the AOA’s new on-demand webinar series, download the AOA’s resource on 2024 physician fee schedule changes or refer to this Medicare Learning Network (MLN) article on G2211. Please note that CMS is still in the process of developing additional guidance, and this document will be updated with the latest information as it becomes available.

What is G2211?

The office/outpatient (O/O) E/M visit complexity add-on code was established to improve payment for the time, intensity and practice expense resources involved when physicians furnish O/O E/M office visit services that enable them to build longitudinal relationships with patients. CMS defines the code to account for “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.”

CMS notes that application of the code “is not based on the characteristics of particular patients but rather the relationship between the patient and the practitioner” and the need to recognize the complexity inherent to O/O E/M visits that is generally unrecognized. As a result, the relationship between the patient and physician for ongoing care is central to billing G2211.

When is it appropriate to bill G2211?

G2211 must be billed with an O/O E/M (99202-99205, 99211-99215). Physicians should bill G2211 if they are:

• the continuing focal point for all needed services; or
• providing ongoing care for a single, serious or complex condition

In practice, this means that the code may be billed for visits addressing one or more chronic conditions, or acute visits where the physician has a longitudinal relationship with the patient and the visit serves as a continuing focal point for all needed health care services. In all cases, the relationship between the patient and physician is central to determining whether G2211 can be billed.

G2211 can be billed for both new and established patients. However, physicians should exercise caution when billing the code on new patient visits and ensure that documentation reflects that the physician intends to take responsibility for ongoing care of the patient. In these instances, CMS medical reviewers will look within the documentation for a treatment plan that defines the need for clinically appropriate ongoing interactions between the physician and patient, and evidence over time that such interactions are indeed occurring.

The G2211 code can also be billed with telehealth E/M services, as G2211 has been added to the list of permanent telehealth services.

When should G2211 not be billed with an E/M?

CMS provides guidance outlining when G2211 may not be billed. This includes when:

• The E/M service is billed with a minor procedure on the same date and appended with a modifier 25 (e.g., when a physician performs OMT and bills an E/M and OMT procedure on the same date with a modifier 25, or when a physician provides an injection of medication, billing code 96372);
• A service is of a discrete or time-limited nature (e.g. removal of a mole, initial onset gastroesophageal reflux disease; treatment for a fracture), no comorbidities are present and/or the work performed by the physician does not relate to continuing or ongoing care;
• A physician does not plan to take responsibility for subsequent, ongoing medical care for a particular patient with consistency and continuity over time; or
• The physician performs services other than 99202-99205 or 99211-99215, such as
  • Non-office E/M visits
  • Annual wellness visits
  • Transitional care management visits

What are the documentation requirements for G2211?

When billing G2211 with an E/M, physicians should continue to follow guidelines for documenting E/Ms and demonstrate medical necessity. CMS has not required additional documentation for G2211 and reviewers will rely on medical records to evaluate medical necessity. Items that can serve as supporting documentation include:

• Information included in the medical record or claims history for a patient/practitioner combination (e.g. diagnoses);
• Assessments and plans for visits; and
• Other services billed.

As previously noted, a treatment plan that defines the need for clinically appropriate ongoing interactions is particularly important when billing G2211 for new patients.

Is G2211 limited to primary care visits?

No, any physician who provides longitudinal care to a patient can bill G2211 for O/O E/M visits where the requirements for billing the code are met. This code will be particularly important for physicians who predominantly provide office-based services.

What does Medicare pay for G2211?

G2211 has a work RVU of 0.33 and a total RVU of 0.49. The national payment amount is $16.05, but this will be adjusted geographically. Patients are responsible for co-insurance and deductible when G2211 is billed, so physicians should be prepared to educate patients about the charge.

Overall, implementation of G2211 presents an opportunity for physicians across specialties to receive improved payment for O/O E/M services and supports physicians who practice osteopathically. For additional details on G2211, as well as other changes implemented under the physician fee schedule, watch the AOA’s on-demand webinars or review the AOA’s online resource.

Related reading:

AOA participates in Biden Administration roundtable on Change Healthcare cyberattack

Change Healthcare disruption update