CJ Wolf
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Our recent webinar on HCPCS Code G2211 brought up lots of great questions – and CJ Wolf, MD, answered them! Check out his insights below.
Q
Has CMS stated if there will be additional guidance provided other than the current MLN articles? My boss is hesitant to use this code because they do not want to be penalized in the future for misusing it due to little guidance provided by CMS.
A
As of the webinar's date, CMS has not indicated they will provide additional guidance beyond the MLN articles. However, MACs could potentially publish additional guidance on their websites.
Q
Would we see this code be used by pain management providers?
A
CMS is not restricting use of this code by medical specialty. It is possible for this code to be used by pain management providers if all the requirements are met.
Q
For behavioral health providers who can bill for E/M codes: Will G2211 be used a lot then since they see these patients on an ongoing basis?
A
CMS is not restricting use of this code by medical specialty. Behavioral health providers could potentially use this code, especially since one of the key requirements is a relationship that enables the provider to build longitudinal relationships with the patient. Remember G2211 can only be reported with 99202-99205 or 99211-99215.
Q
Provider documents they spent 45 minutes with the patient also including the assessment and plan. Charges a 99215 but also adds G2211, but nothing else is documented. Can this be used?
A
It will depend on the specific medical record documentation for that patient. One of the key requirements is demonstrating an evaluation and management visit 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)
Q
Can you use this code with wound care patients?
A
CMS is not restricting use of this code by medical specialty. Clinicians caring for a patient’s wound(s) could potentially use this code. One of the key requirements is a visit that provides care and enables the provider to build longitudinal relationships with the patient. Remember G2211 can only be reported with 99202-99205 or 99211-99215.
Q
According to CMS, providers from the same specialty are considered one. Would this code apply to specialty or to specific provider?
A
The code is not specialty or provider specific. If a visit and the medical documentation meet the requirements for using this code, it can be reported.
Q
How would this pertain to training facilities where we have residents? Would it be acceptable that a resident bill for this since they are meeting the longitudinal relationship with the patient? What happens when another provider is seeing the patient that is part of the resident's team?
A
CMS has not given additional guidance in the teaching physician context. However, there is nothing specifically prohibited about its use in a teaching physician context. The service will need to meet the requirements for the code for the clinician in whose name the evaluation and management code is being billed. There are likely many scenarios where this will not be accomplished in a teaching physician setting.
Q
Can different providers within the same office see a patient, even though it is not who they normally see. Example: their primary care provider was unavailable.
A
CMS has not specifically addressed this scenario. The provider that is billing the service needs to meet the requirements for reporting G2211. Since a key requirement for this code is the longitudinal nature of the provider/patient relationship, this may be unlikely in the scenario in your question.
Q
How would you apply this code for a specialty like Radiation Oncology where the provider sees a patient for the initial consult and determines that the patient is a candidate for radiation treatment. Typically, a patient will have treatment for several weeks and then return for routine 6 weeks, 3 month, 6 month, etc., follow up. This is standard of care but would the G2211 be billed for every patient in this case?
A
Billing for “every patient in this case” is not advised. Each unique visit and medical documentation needs to be separately determined to meet the requirements for reporting the code. CMS is not restricting use of this code by medical specialty. One of the key requirements is a visit that provides care and enables the provider to build longitudinal relationships with the patient. Remember G2211 can only be reported with 99202-99205 or 99211-99215.
Q
Don't you think that claims review by the carrier should be enough to support longitudinal care for most patients instead of the physician documenting that this is longitudinal care?
A
A longitudinal care relationship is not the only requirement for reporting this code. The documentation should also support the visit for which G221 is being reported was 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.
Q
Please correct me if I am wrong but a patient DOES NOT have to have a chronic or complex condition in order to report this code?
A
That is correct. The code descriptor specifically states “and/or.” It reads: “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.”
Q
Will FQHCs and RHCs be reimbursed by Medicare for this code?
A
If the payment/reimbursement structure is such that the physician services are bundled into some other payment, it is unlikely that G2211 will be reimbursed separately.
Q
Can we use this code with every specialty office visit?
A
CMS is not restricting use of this code by medical specialty. G2211 can only be reported with 99202-99205 or 99211-99215.
Q
Any suggestions on how to argue this? we are having an issue with Indiana Medicaid and a few others stating this in non-payable. We're disputing so much but it doesn't seem to be getting anywhere.
A
Medical coding and reimbursement are two different things. G2211 is a valid HCPCS code. Payors generally decide their coverage criteria. One might consider submitting some of the language from the Final Rule discussed in the webinar to demonstrate that CMS states there is additional visit complexity not always captured in evaluation and management codes alone. That is why they created the code.
Q
Thinking about cardiology - so if we are managing a patient with heart failure this would be a good code to add on?
A
Reporting this code needs to be considered on a visit by visit, patient by patient basis. CMS is not restricting use of this code by medical specialty. Recall, one of the key requirements is a visit that provides care and enables the provider to build longitudinal relationships with the patient. G2211 can only be reported with 99202-99205 or 99211-99215.
Q
If the provider is using time as a factor for determining the E/M code would this affect using G2211?
A
It will depend on the documentation and what services were provided during the visit. The services provided must be 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.
Q
If the patient tells the provider about their Grandchild getting accepted to a university and the provider documents that, would that be a relationship factor?
A
It would be difficult to answer this question without reviewing the medical documentation in its entirety, but generally speaking, that does not appear to contribute to the type of relationship described in the final rule by CMS.
Q
Is there a frequency limitation as to how many times this can be billed for the patient?
A
No
Q
Can primary care and specialists addressing chronic conditions bill this code concurrently?
A
Yes, if all requirements are met for each individual visit with the respective provider.
Q
What is the reimbursement rate for G2211?
A
The reimbursement rate will vary by geographic location and date. For 2024, the Medicare, national, non-facility and facility rate is $16.05.
Q
When the provider uses "words" to communicate the care/complexity/longitudinal nature in the encounter, can or should it be entered with a macro/template/smart phrase that gets created and dropped into the note to support this code?
A
The mechanism by which medical documentation is generated is not generally regulated. Medical record documentation needs to be accurate, and the services need to be medically necessary. Individual organizations might have their own internal policies on the use of macros or templates.
Q
Can G2211 be used with the telehealth codes ---99441,99442,99443?
A
No
Q
Are we to interpret this as (1) single, serious condition or complex condition OR (2) single OR serious OR complex condition?
A
We believe the correct interpretation is "single, serious condition or a complex condition."
Q
If G2211 includes practice expense, wouldn't we be double dipping if we bill G2211 as well as G0463 for POS 19 or 22?
A
G0463 is used only for Medicare OPPS. It is not priced separately under the Medicare Physician Fee Schedule. Additionally, G2211 has a status of “B” under Medicare OPPS and is not separately reimbursed under OPPS.
Q
Would this code only be used once per patient with the Provider that is establishing a longitudinal relationship? Or can we use it on multiple visits for one patient for the same provider? For example, if patient has chronic hypertension that is uncontrolled, and the physician has her coming back monthly to try to get it under control and at each visit she addresses daily lifestyle changes that the patient could try and then after each visit they set up a return visit. Would I be able to use G2211 on all these visits?
A
Use of G2211 is determined for each individual visit. If the requirements are met on subsequent visits, it may be reported each time.
Q
Does the provider that will report this code initially should also be the follow-up provider?
A
A key element of G2211 is the development of a longitudinal relationship. Additionally, G2211 represents 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. As such, one would anticipate there to be follow-up visits planned with the provider.
Q
We are getting a lot of patient complaints regarding cost sharing related to G2211. Do you suggestions for the best way to explain this additional charge to the patient in laymen's terms? Thanks!
A
There are likely a number of ways to do this depending on the patient personality and level of understanding. However, we believe it makes the most sense to be direct and as clear as possible. Perhaps something like, "Dr._______ is also monitoring your conditions on a long-term basis and is serving as your primary contact for questions about your ongoing health care services."
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