At the start of 2024, the Centers for Medicare and Medicaid Services (CMS) inaugurated a new HCPCS add-on code, +G2211. The purpose of this new code is to compensate primary care providers and specialists for the time and costs involved in building longitudinal relationships with patients over a longer period. However, the code’s definition of “visit complexity” is not straightforward and may be confusing, particularly for those not expected to use it frequently, such as retina specialists.
Q. Which E/M services can be reported with +G2211?
A. The HCPCS parenthetical instruction for +G2211 says it should be “[listed] separately in addition to office/outpatient evaluation and management visit, new or established.” However, +G2211 cannot be combined with any other service, such as inpatient E/M or eye codes (920xx). Also, it should not be reported with 99211 or when an E/M service is reported with modifier -25 (Table 1).
Table 1: When Is +G2211 Supported?
|
Does Not Support +G2211 |
Supports +G2211 |
|
CPT 99211 |
CPT 9920x, 99212, or higher |
|
Discrete, routine, or time-limited care |
Ongoing, longitudinal, continuous care |
|
E/M code with modifiers 24 or 25 |
E/M code unrelated to surgery |
|
Exam to decide on surgery |
Complex medical (not surgical) care |
|
Focused on a part of patient’s health care |
Plan all or most of patient’s health care |
|
Independent care, uncoordinated |
Team-based care, coordinated |
|
Inpatient E/M, eye code (920xx) |
Office or outpatient E/M only |
|
Limited scope of care, circumscribed care |
Comprehensive, integrated care |
|
Solitary, separate, independent care |
Collaborative with other providers |
|
Transfer of care, referral |
Q. What providers can report code +G2211?
A. All physicians may use +G2211. However, CMS expects that primary care doctors will use the add-on code more than specialists, because they are the most likely to establish longitudinal care relationships with patients. According to CMS, surgical specialties will have the lowest use. It is noteworthy that, according to CMS, “primary care specialties” does not include ophthalmology or optometry.
Q. What is the value of +G2211?
A. The national, unadjusted allowed amount for HCPCS code +G2211 is $16.04.
Q. Do other third-party payors pay for +G2211?
A. HCPCS code G2211 was created for use in the Medicare program, and coverage is at the discretion of the Medicare Administrative Contractor (MAC), so verify the relevant local coverage determination. Private payors are not required to cover and pay separately for +G2211; always identify the payor and check their published policies.
Q. Can vitreoretinal physicians use +G2211?
A. Yes, but rarely if at all. The characteristics that define this add-on code are not typically applicable in ophthalmology or optometry, because surgeries to resolve a specific issue (such as a cataract), treatment related to ocular trauma, and other time-limited conditions would not be billable using G2211. The frequent use of it is only expected for primary care specialties, and postpayment audits are likely if payors perceive the add-on code is used inappropriately.
The determining factor for whether to use G2211 is the relationship between the patient and practitioner, and the collaborative care plan must be documented in the patient’s medical record. RP
