Starting January 1, 2024, the Centers for Medicare & Medicaid Services (CMS) began allowing payment on the Evaluation and Management (E/M) add-on code G2211. The implementation of G2211 aims to capture the inherent complexity of certain patient visits, especially those reflecting the ongoing, long-term relationship between a healthcare provider and patient. G2211 recognizes the additional cognitive work involved in managing ongoing patient care, accounting for factors such as chronic conditions, social determinants of health, and the cumulative impact of health issues that require continuous attention. By using G2211, healthcare providers can more accurately reflect the time and resources invested in complex patient cases.
Who Should Bill G2211
It is appropriate to bill G2211 if you are the focal point for all the needed services for the patient and/or you are providing care for a single, serious or complex condition.
G2211 is expected to be used mainly by primary care providers. However, specialists can bill for the G2211 as long as the encounter supports the single, serious or complex condition. This can look different for each specialty based on the nature of the practice. It does not matter if the patient is new or established, as the code can be applied to both.
How and When to Bill G2211
G2211 is appended to the E/M level and is paid separately from the E/M level. The co-insurance and deductible still apply to G2211, as they do at the E/M level. Modifier 25 is not appropriate to add to the E/M level when also billing for the G2211, since the G2211 is an add-on code.
There are some scenarios where G2211 would not be appropriate to bill along with the E/M. If you are providing care to a patient that is discrete, routine or time-limited in nature, for instance, you would not use G2211 as an add-on code to the E/M level. Additionally, if the claim also contains modifiers 24, 25 or 26, you should not use G2211.
When deciding if G2211 is appropriate to bill, ask yourself the following questions:
If you answered yes to the first question and no to the last two questions, then G2211 is appropriate to bill. If you answered differently than above, then G2211 is not appropriate to bill.
When used correctly, G2211 allows providers to accurately reflect the complexity of care in cases requiring ongoing management and deeper involvement, especially for patients with chronic, serious, or complex conditions. By understanding when to apply this code, providers can ensure fair compensation for their work.
If you have any questions about G2211 or other healthcare billing matters, please contact us to learn more.
Samantha Joswick is an Auditor I at Medic Management Group. MMG is a national provider of advisory and consulting competencies, transaction support services, and back office administrative support to independent and system owned physician practice groups.