About CPT G2211 & Objectives
Effective from January 1, 2024, the Centers for Medicare and Medicaid Services (CMS) began reimbursing for G2211, an HCPCS add-on code meant to be billed alongside an office or outpatient evaluation and management (E/M) code in certain situations.
This results in higher payment for the E/M service, regardless of its level. The national payment rate for G2211 is $16.05.
CPT code G2211 was originally proposed by CMS in 2021 to more accurately reflect the costs associated with providing care for patients over extended periods, such as during primary care or specialist encounters.
However, due to budget neutrality concerns and the anticipated impact on physician payments, Congress delayed the implementation of this code for several years. 2024 marks the first year that G2211 can be billed and reimbursed.
CPT Code Description
CPT G2211 - 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)
This add-on code acknowledges the payment effective from Jan 1st, 2024 for Medicare & Medicare Advantage plan, Medicare HMO's and required when a provider delivers consistent, continuous services for a patient's ongoing care.
These visits must be medically reasonable and necessary for the practitioner to report CPT code G2211 alongside of office and outpatient codes .
The documentation should demonstrate the medical necessity of the level of E/M visit. While the CMS not specified require any specific additional documentation for billing of CPT G2211.
The services may need to meet the following criteria to fulfill the billing requirements for CPT code G2211,
- Treatment of respective problems,
- Management of the conditions,
- Care coordination,
- Patient education,
- Shared decision-making,
- Commitment to achieving health goals.
Who Can Bill CPT G2211
Any practitioner, regardless of specialty, may bill for G2211 if the medical documentation supports the use of the code.
When Can Bill CPT G2211
If a provider is delivering ongoing care for a single, serious condition or a complex condition such as sickle cell disease or HIV, The CPT code G2211 may be reported along with office and outpatient E/M codes 99202 to 99215
Key Factor
CPT G2211 should not be added in every claim/visits for the office or outpatient E/M services. The documentation and the relationship between the provider and the patient must support the use of the code.
The patients may be responsible for additional deductibles and coinsurance payments when this code is billed under the Medicare program.
Coverage
Recent research indicates that coverage for CPT code G2211 is expanding beyond direct Medicare to include some Medicare Advantage plans, Medicare HMO's, and commercial payers. Examples are below,
As of March 1, 2024, three national payers have confirmed coverage of CPT code G2211,
- Cigna (Medicare Advantage only),
- Humana (commercial and Medicare Advantage),
- United Healthcare (commercial and Medicare Advantage).
Do Not Use
G2211 cannot be used in the inpatient hospital or skilled nursing setting.
G2211 cannot be used with audio only telephone services (99441 – 99443)
G2211 cannot be billed when the E/M code is billed with modifier 25.
G2211 may not be used when a procedure is performed on the same day, by the same practitioner.
G2211 cannot be used for acute care.
G2211 payers will not reimburse you unless you report it with an appropriate primary code.
