G2211 CMS HCPCS Add-On Code

Evaluation and Management (E/M Visits)

On January 1, 2024, CMS finalized implementing a separate add-on payment for Healthcare Common Procedure Coding System (HCPCS) code G2211. CMS code G2211 defines 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).

What does G2211 mean?

This code, identified as G2211, was created to better account for the costs of resources related to primary care and other forms of long-term (longitudinal) medical care. The G2211 code used is based on the continued responsibility of the clinician for the patient rather than the patient’s specific condition.

It’s also important to recognize that there may be ongoing medical care required for a patient’s single, serious condition, or complex condition, even if the clinician is not the focal point for all necessary healthcare services. For instance, CMS provides an example of a patient with HIV who receives ongoing care from an infectious disease doctor.

G2211 utilization

G2211 is an add-on code that may be reported with new and established patient office/outpatient evaluation and management (E/M) services.

• Use the add-on code if you are the continuing focal point for all health care services the patient needs.
• According to CMS, code G2211 can be added to office/outpatient E/M visits (99202-99205 or 99211-99215) based on the clinician’s continued responsibility for the patient, not based on the patient’s clinical condition.
• Furthermore, G2211 can be justified even if the clinician is not the focal point for all services but has an ongoing relationship with the patient for a “single, serious condition or complex condition.”

Do Not Use G2211

• The associated office visit E/M is reported with modifier 25 appended.
• Your relationship with the patient is discreet, routine, or time-limited. An example is an acute concern should not report HCPCS G2211 if they have not also assumed responsibility for the patient’s ongoing medical care or do not plan to take responsibility for subsequent, ongoing medical care with consistency and continuity over time.[1]

Payment

According to the AAFP FPM article, “Medicare’s national payment amount for G2211 is $16.05; the actual allowance will vary geographically.  This will be subject to the patient’s deductible and coinsurance. Practices should be prepared to explain this additional charge to patients.”  Once physicians are familiar with this new G2211 code, CMS estimates that more than half of the office/outpatient services will use it.  There is a chance this code could bring in income for the practice depending on the number of visits per day and days per year and if half of the visits qualify for the new G2211 code.

[1] https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/evaluation-management/G2211-what-it-is-and-how-to-use-it.html

https://www.aafp.org/pubs/fpm/content/coding-G2211.html