Background

With the release of the Calendar Year (CY) 2024 Medicare Physician Fee Schedule final rule, the Centers for Medicare & Medicaid Services (CMS) finalized policy that allows payment for services described by HCPCS code G2211.

First proposed by CMS for implementation in CY 2021 and delayed by Congress for three years, HCPCS code G2211 was created to recognize the additional resource costs associated with providing care for a single or multiple complex or serious conditions for which the billing practitioner is or will become the “continuing focal point” for all the care required by the patient or all the care related to the condition(s). The code acknowledges the work and time involved in building a trusting patient-physician relationship and was created to capture work associated with “primary and longitudinal care that has been previously unrecognized and unaccounted for during evaluation and management visits.” 

Guidelines for Using G2211

• G2211 is an add-on code and may only be reported on claims with a new or established outpatient evaluation and management (E/M) service (99202-99205, 99211-99215).
• G2211 can be reported by any provider (physicians, advanced practice providers) who can report E/M services.
• G2211 can be reported with telehealth and audio-only services.
• Note: The most important factor in determining when to bill for services captured by G2211 is whether a longitudinal relationship exists or is being developed between the patient and the practitioner. It should not be reported when the practitioner’s relationship with the patient is of a discrete, routine, or time-limited nature.
• G2211 may not be reported when a procedure is performed on the same day, by the same practitioner, and the E/M service is appended with Modifier -25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service is appended to the E/M service).
• Any practitioner, regardless of specialty may bill for G2211 if medical documentation supports the use of the code.
• Team-based physicians (e.g., transplant teams) and physicians within the same group practice and with the same specialty designation may bill G2211 for the same patient.

G2211 should not be added to every claim billed for office/outpatient E/M services. Documentation and the relationship between the provider and the patient must support the use of the code.

Patients will be responsible for additional deductibles and coinsurance payments when this code is billed under the Medicare program.

Private payers such as Medicaid, Medicare Advantage, and commercial insurance companies are not required to pay for services associated with G2211 and coverage will vary.

Documentation

• Document the outpatient E/M service, including medical necessity and time spent (if applicable).
• Consistent diagnosis coding is a crucial component of the documentation for G2211. CMS may review documentation in the medical record or claims history that shows the required patient and practitioner relationship, which may be indicated by consistent use of the same diagnosis over time.
• The practitioner’s assessment and plan for the visit that includes clear direction and a care plan demonstrating patient return and continued care for the patient and/or condition.
• If the visit is unrelated to the treatment of an ongoing medical issue, the note should indicate that the patient is returning to the practice.
• Other service codes billed.

Payment for G2211

*This amount will vary by geographic location and other factors.

Clinical Examples

• A patient with advanced prostate cancer presents to the urologist for a six-month checkup. The patient has been seeing the urologist for five years. G2211 may be billed, when appropriately documented, describe the longitudinal relationship between the physician and the patient and is based upon the criteria that the visit was for medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition.
• A patient with advanced prostate cancer presents to the urologist for a six-month checkup. The patient has been seeing the urologist for five years. The patient has noted a recent onset of gross hematuria. A cystoscopy is performed the same day as the office visit. G2211 is not reported with the E/M office service despite the longitudinal relationship, because modifier 25 would be appended to the E/M service.
  
  
• A patient of five years with advanced prostate cancer presents to their urologist, for an emergency visit due to dysuria, well before the typical six-month checkup. The patient is diagnosed with a urinary tract infection (UTI) and antibiotics are prescribed. The provider chooses the workup and treatment plan in context of the patient’s underlying complex condition. G2211 may be appended to the E/M service due to the longitudinal relationship, despite the acute nature of the UTI, as the treatment plan was chosen based upon the ongoing care related to a patient's single, serious condition or a complex condition.
  
  
• A patient with BPH presents a urologist with dysuria. A UTI is diagnosed, and the patient treated. G2211 is not appended to the E/M service because it is not clear if the provider will establish a longitudinal relationship with the patient due to the nature of the presenting problem which is of a discrete, routine, or time-limited nature.
  
  
• A patient with BPH presents to the urologist’s office with dysuria. He has been seeing the urologist for years for significant BPH with recurrent UTI’s. The urologist’s Physician’s Assistant (PA) sees the patient. The PA reviews the chart and treats the patient in context of the patient’s longstanding chronic issues. G2211 may appended to the E/M service due to the longitudinal relationship that the practice has with the patient and based upon the criteria that the visit was for medical care services that are part of ongoing care related to a patient's single, serious condition or a complex condition.