G2211 approved by Medicare as of January 1, 2024

G2211 has been approved by Medicare as of January 1, 2024. G2211 is an add on code to the office and outpatient (O/O) evaluation and management (E/M) codes, including telehealth visits. The applicable E/M codes include 99202-99205 and 99211-99215. The reimbursement value is $16.04 in 2024. The code recognizes the extra work required to chronically manage complex medical conditions when providing ongoing medical care.  Specifically, this code would apply if you are the continuing focal point for all needed services, like a primary care practitioner, or if you are providing ongoing care for a single, serious condition or a complex condition. This add on code is available when providing care to new and established patients where there is intent to continue an ongoing relationship and to manage these ongoing complex medical conditions. This code is particularly meant to help offset the time/expense involved in managing these conditions between visits. It has been approved and is now recognized by Medicare. It is unclear whether commercial insurers will follow-suit and similarly cover and provide payment for this code. On January 24, 2024, CMS held a Physicians, Nurses & Allied Health Professionals Open Door Forum and discussed G2211; the agency emphasized that the most important information used to determine appropriate use of G2211 code is the relationship between the practitioner and the patient. The agency is expected to release additional information and resources related to the implementation of this code. With the approval of this code, there are three big “NOs...”

1. G2211 is not payable when you report the O/O E/M visit with payment modifier 25. If an OMT service is provided with an E/M service, the E/M service must be reported using modifier 25 and therefore, the add on code would not be available for that E/M service.
2. Do not use this code unless you are treating a patient's single, serious condition or a complex condition. “Complex” has not yet been defined but examples provided by CMS include sickle cell disease and HIV.
3. Do not use this code unless there is intent to follow the patient and this condition on an ongoing basis. The code is meant to capture the “longitudinal,” or continuous, nature of the practitioner and patient relationship.

With approval of this code, the big “YESes…”

1. Start using it immediately where there are no “nos.”
2. Documentation requirements. According to CMS, you must document the reason for billing the O/O E/M visit. The visits themselves need to be medically reasonable and necessary for the practitioner to report G2211. In addition, the documentation would need to illustrate medical necessity of the O/O E/M visit. Medical reviewers may use the medical record documentation to confirm the medical necessity of the visit and accuracy of the documentation of the time spent. These following items could serve as supporting documentation for billing code G2211:
   • Information included in the medical record or in the claims history for a patient/practitioner combination, such as diagnoses;
   • The practitioner’s assessment and plan for the visit; and
   • Other service codes billed.

Additional CMS guidance documents are available:

1. How to Use the Office & Outpatient Evaluation and Management Visit Complexity Add-on Code G2211 
2. Edits to Prevent Payment of G2211 with Office/Outpatient Evaluation and Management Visit and Modifier 25
3. Guidance for the Implementation of the Office and Outpatient (O/O) Evaluation and Management (E/M) Visit Complexity Add-on Code G2211

CMS has stated they are developing an FAQ document that will be released in the near future.