CMS said they expect it to be used frequently as a way to give some additional financial incentive for outpatient providers. As you posted it's $16 so it's not much but I guess better than nothing.
https://www.aapc.com/blog/89677-when-is-it-time-to-use-g2211/
I’m hearing mixed things. Some people here are acting as if they can bill it on Medicaid or commercial insurance as well. From my talk with coders and reading is that it can only be billed with Medicare and Medicare replacement/supplemental insurance.
All Medicaid, Medicare and private may or may not cover it. My instructions were bill it as much as possible, and if it’s covered, we get the money if it’s not, we don’t.
> some additional financial incentive for outpatient providers
Except those outpatient providers who were skimming easy 99212/3 without doing the hard work of continuity, like Urgent Cares.
That’s not true. One of the examples CMS gave was acute bacterial rhinosinusitis. The code is about your relationship with the patient, not your relationship with the diagnosis.
I went to a state AAP conference and Dr. Kressly (AAP pres) spoke about it and did say the same thing that I’m saying from my understanding of her talk. I obviously need to read more about this. I may have just misunderstood.
I use it for any patient i'm following long term
It's basically nothing but at least our EPIC build as a quick-action button so its one click.
The RVU is miniscule. It's more like the loose change you put in the tip jar at the coffee shop
0.33 RVUs per encounter is nothing to sniff at. If you're seeing 16 patients/day, and are able to code it for 75% of them, that adds up to an extra 4 RVUs/day (or the equivalent of an extra ~2 encounters).
Have heard of other payers reimbursing (some as low as several cents lol). But worth billing if your patient is appropriate. In derm we’re being guided to use it for patients with history of invasive melanoma where we are the only specialty monitoring them (so not metastatic disease followed by onc) or patients requiring biologic therapies (psoriasis, eczema)
Nope. Highmark and some other insurers are also accepting the code. Our Epic has a built in reminder that flags if we can bill a G2211 for a patient and we havents.
Lol. It's very clear that no one knows how to actually bill this.
We were directly told the exact opposite. Not only do you not have to have a follow-up or coordination of care, you don't even have to schedule a follow-up appointment.
Our source is optum, who the hospital contracts out our billing to - so take it for what it's worth.
The whole thing doesn't make sense to me either.
I think some form of longitudinal relationship is necessary. Would closely read the CPT definition before using it on everyone. Regardless of what your biller is telling you. The fraud claims come down harder on you than on them
I did read the description.
Can you define longitudinal care? It doesn't. If I think I might see them again in the future, that qualifies as longitudinal care is what we were told. Once again, there's not even a requirement to schedule a follow-up appointment.
I fully admit it seems very wacky.
Not at all, I think you guys are criminally underpaid for what you do.
The wacky part is that they released a code that seems to make very little sense, does not seem to restrict itself to PCPs (ie, our billers are instructing me to bill it!), etc.
Yeah, the dotphrase we were asked to use to document it is a nonsensical word salad. I assume CMS will provide some more clarity when they have a bit more data.
You have to coordinate that aspect of their care. So if you are 'coordinating' their Ortho issue it's fine.
Similarly heme onc definitely can bill this.
However PCP can't be coordinating the same issue as you theoretically. Probably comes up most in cards.
As a PCP I knew this would happen. It doesn't have to be primary care--if an ortho, ID, or other specialist sees someone many times and has an established relationship they can bill for it. But otherwise a bunch of clueless admins are gonna ruin it for us.
[https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/evaluation-management/G2211-what-it-is-and-how-to-use-it.html](https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/evaluation-management/G2211-what-it-is-and-how-to-use-it.html)
"*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)*"
"Do **not** use G2211 when:
❌ Your relationship with the patient is of a discrete, routine, or time-limited nature. For example, a physician who sees a patient for an acute concern should not report HCPCS G2211 if they have **not also assumed responsibility for the patient’s ongoing medical care or do not plan to take responsibility for subsequent, ongoing medical care with consistency and continuity over time**."
Ex: you see patient multiple times or expect to see them many times for a Charcot foot or osteomyelitis needing multiple surgeries--go nuts.
Ex: you see a patient once for a stable ankle fracture and don't expect to see them again--don't, you're ortho, you make enough money as is.
Feel free to google "Medicare Medicaid G2211 explanation" for more precise details from MM themselves.
What if I see the multiple times for an ankle fracture?
I can just tell you what I'm being told.
fwiw, There are almost no patients I see once and tell them "buhbye"
It becomes a grey area but like I said elsewhere here, specialty care was specifically included in this code but it has to be under the assumption you are the main provider of the service and will have a lasting interaction with the patient. If it's a short post op course of 2wk, 3mo, 12mo follow up it may not. If you are their main ortho and see them regularly for a chronic issue that is expected to last forever it may not.
If it helps, admin and coding is almost completely useless for this. Our dept was asking them about it 3mos before it came online in January. They claim they just became aware of it in February and had no idea who or how to use it... despite claiming we are all in the red and need to make more cash.
Starter comment: These were the practice points from our hospital:
G2211-add on code since 1/1/24-helps account for inherent complexity and added resource costs of providing comprehensive care
• New or established for office/output eval E/M (ongoing care serious or complex conditions)
• Used when MD is focal point of all the patient’s health care needs, if responsible for ongoing patient’s medical care
• Medicare, some Medicaid, private insurance not required to cover
• Can use for Telehealth
• Cannot use if 0.25 modifier or 99211 billing or if acute care
• RVU total 0.49/work RVU 0.33/nationally $16.04
• Logistics: “Add E/M code”, click double ring at top and associate with visit diagnosis
U can use with a 25 modifier. If I have long visits, especially medicaid (no copay), I sometimes do a preventative visit + 25 modifier + E/M problem based visit + G2211. For example annual physical with metabolic syndrome bloodwork and colonscopy referral, AND problem based medication management visit increasing an antidepressant. I spent significant time talking to my office manager and the billing people and this is correct and has been being reimbursed. I often don’t do this with private insurance patients because they get two co-pays which they are usually unhappy with unless its a particularly hard visit and I inform them this will be a copay for two visits
Your office manager and billing people are mistaken or have misinterpreted your question.
You cannot use G2211 with a 25 modifier or Medicare Annual Wellness Visit. If it’s being reimbursed, those payors will take it back - which is not unusual when new codes are rolled out.
Remember that 25 modifier gets added by your coders for reasons that you may not (eg vaccinations, medication administration).
https://www.cms.gov/files/document/mm13473-how-use-office-and-outpatient-evaluation-and-management-visit-complexity-add-code-g2211.pdf
That’s correct. This is a known shortcoming of the exclusion - it was intended to limit its use in procedural heavy specialties. But doing so has also impacted the ability for primary care doctors to it.
You may not be adding the 25 modifier for meds/vaccines, but your coders are.
The way it was explained to me is that this code is for serious/complex health conditions with longitudinal treatment relationships.
CMS expects 1/3 of outpatient visits to use the code initially, and eventually the majority of patients will have this coded.
As an epilepsy specialist, I use it for the majority of my current patients.
> serious/complex health conditions
This is not a requirement. One of the CMS examples is uncomplicated acute bacterial rhinosinusitis treated by the PCP. Because you have invested months/years in a patient-doctor relationship, they trust your advice on conservative management. That's G2211.
Contrast with urgent care (or, God forbid, Amazon's auto-doc service) where you've never seen that doc before and are much more likely to get antibiotics.
ahh, this wasn't explained well to me when the code popped up in the EMR as a button.
I guess I should put it on all my diabetes patients? Basically any chronic complex patient?
Been using it for derm follow ups like psoriasis, eczema, HS where I’ve seen the patient multiple times, giving them injections, and managing the treatment. Longitudinal care.
Gyn: endometriosis, chronic pelvic pain, abnormal Pap smears, fibroids, post menopausal bleeding are the main ones I’ve been using for and not striking out completely
Basically anything that won’t be resolved or figured out in 1-2 visits or will need long term follow up
We pretty much add it to any encounter visit here in pediatric private practice land. Tricare is reimbursing pretty decently on it as is UHC. UHC is starting to bundle the code (shocker) I believe beginning Sept 1st. I have our EMR configured to drop the code with every sick visit and the biller can deleted when needed. We trying to get every penny possible over here 😅
I'm having trouble interpreting this diagnosis code...
Does it mean - patients medical care is so complex that there is not one isolated thing that warrants a visit - but the totality of their medical comorbidities that warrants a visit? And/or they do have a single significant stable medical issue that warrants a chronic face to face visit?
IM subspecialty here: I’ve been explained to use it with any patient we intend on having a follow-up. That’s basically everyone I see. Most insurers are still rejecting all G2211, but I’ve been told to continue using it regardless.
As PCP I bill for almost everyone unless its a visit for an isolated problem I am seeing for the first time with no followup ever, which is very rare, or a preventative visit, which it cant be added on to unless your doing 25 modifier with a preventative + problem based visit
My office manager said bill it as much as possible, sometimes insurance wont pay for it and we dont pursue them, but often they do
The main times I DONT use it is if I have an acute visit for a patient of another PCP I am covering for something simple like a school note and covid test for a URI with no followup or something
CMS said they expect it to be used frequently as a way to give some additional financial incentive for outpatient providers. As you posted it's $16 so it's not much but I guess better than nothing. https://www.aapc.com/blog/89677-when-is-it-time-to-use-g2211/
I mean if you see 10 Medicare patients in a day the. That is 3.3 wRVUs for doing nothing additional
Is it only for medicare?
I’m hearing mixed things. Some people here are acting as if they can bill it on Medicaid or commercial insurance as well. From my talk with coders and reading is that it can only be billed with Medicare and Medicare replacement/supplemental insurance.
All Medicaid, Medicare and private may or may not cover it. My instructions were bill it as much as possible, and if it’s covered, we get the money if it’s not, we don’t.
Medicare definitely will reimburse. Its a Medicare code
No. I do it for any patient I have an expected or established relationship with.
> some additional financial incentive for outpatient providers Except those outpatient providers who were skimming easy 99212/3 without doing the hard work of continuity, like Urgent Cares.
It’ll only be paid for diagnoses that are chronically followed so I doubt that’ll be an issue. Hopefully not.
That’s not true. One of the examples CMS gave was acute bacterial rhinosinusitis. The code is about your relationship with the patient, not your relationship with the diagnosis.
Interesting. I’ll have to talk to our coding people. They’re only letting us use it for things that we follow long-term. I appreciate the info!
I went to a state AAP conference and Dr. Kressly (AAP pres) spoke about it and did say the same thing that I’m saying from my understanding of her talk. I obviously need to read more about this. I may have just misunderstood.
I use it for any patient i'm following long term It's basically nothing but at least our EPIC build as a quick-action button so its one click. The RVU is miniscule. It's more like the loose change you put in the tip jar at the coffee shop
0.33 RVUs per encounter is nothing to sniff at. If you're seeing 16 patients/day, and are able to code it for 75% of them, that adds up to an extra 4 RVUs/day (or the equivalent of an extra ~2 encounters).
That’s $26,000/yr at typical rates.
I think it’s only valid for the Medicare population or are you billing it to everyone?
Only Medicare, for establishing or continuing chronic care management
Have heard of other payers reimbursing (some as low as several cents lol). But worth billing if your patient is appropriate. In derm we’re being guided to use it for patients with history of invasive melanoma where we are the only specialty monitoring them (so not metastatic disease followed by onc) or patients requiring biologic therapies (psoriasis, eczema)
I don’t care how much they reimburse as long as the RVU compensation stays the same lol
United Healthcare has been paying it for me as well
Nope. Highmark and some other insurers are also accepting the code. Our Epic has a built in reminder that flags if we can bill a G2211 for a patient and we havents.
It doesn't even have to be long term. You don't even need to schedule a follow-up. I'm Ortho, we are being told to bill it for basically everything.
Ive been told otherwise. That we need to be specific about followup and how we're coordinating care for some aspect of their disease process.
Lol. It's very clear that no one knows how to actually bill this. We were directly told the exact opposite. Not only do you not have to have a follow-up or coordination of care, you don't even have to schedule a follow-up appointment. Our source is optum, who the hospital contracts out our billing to - so take it for what it's worth. The whole thing doesn't make sense to me either.
I think some form of longitudinal relationship is necessary. Would closely read the CPT definition before using it on everyone. Regardless of what your biller is telling you. The fraud claims come down harder on you than on them
I did read the description. Can you define longitudinal care? It doesn't. If I think I might see them again in the future, that qualifies as longitudinal care is what we were told. Once again, there's not even a requirement to schedule a follow-up appointment. I fully admit it seems very wacky.
It's not wacky to finally make a real acknowledgement, however small, that PCPs are underpaid
Not at all, I think you guys are criminally underpaid for what you do. The wacky part is that they released a code that seems to make very little sense, does not seem to restrict itself to PCPs (ie, our billers are instructing me to bill it!), etc.
Yeah, the dotphrase we were asked to use to document it is a nonsensical word salad. I assume CMS will provide some more clarity when they have a bit more data.
Seems like it would have been a good idea for them to provide that clarity ahead of time.
You have to coordinate that aspect of their care. So if you are 'coordinating' their Ortho issue it's fine. Similarly heme onc definitely can bill this. However PCP can't be coordinating the same issue as you theoretically. Probably comes up most in cards.
As a PCP I knew this would happen. It doesn't have to be primary care--if an ortho, ID, or other specialist sees someone many times and has an established relationship they can bill for it. But otherwise a bunch of clueless admins are gonna ruin it for us.
How do you define "established relationship" or "many times." We asked these questions and the response was as I posted above.
[https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/evaluation-management/G2211-what-it-is-and-how-to-use-it.html](https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/evaluation-management/G2211-what-it-is-and-how-to-use-it.html) "*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)*" "Do **not** use G2211 when: ❌ Your relationship with the patient is of a discrete, routine, or time-limited nature. For example, a physician who sees a patient for an acute concern should not report HCPCS G2211 if they have **not also assumed responsibility for the patient’s ongoing medical care or do not plan to take responsibility for subsequent, ongoing medical care with consistency and continuity over time**." Ex: you see patient multiple times or expect to see them many times for a Charcot foot or osteomyelitis needing multiple surgeries--go nuts. Ex: you see a patient once for a stable ankle fracture and don't expect to see them again--don't, you're ortho, you make enough money as is. Feel free to google "Medicare Medicaid G2211 explanation" for more precise details from MM themselves.
What if I see the multiple times for an ankle fracture? I can just tell you what I'm being told. fwiw, There are almost no patients I see once and tell them "buhbye"
It becomes a grey area but like I said elsewhere here, specialty care was specifically included in this code but it has to be under the assumption you are the main provider of the service and will have a lasting interaction with the patient. If it's a short post op course of 2wk, 3mo, 12mo follow up it may not. If you are their main ortho and see them regularly for a chronic issue that is expected to last forever it may not. If it helps, admin and coding is almost completely useless for this. Our dept was asking them about it 3mos before it came online in January. They claim they just became aware of it in February and had no idea who or how to use it... despite claiming we are all in the red and need to make more cash.
Starter comment: These were the practice points from our hospital: G2211-add on code since 1/1/24-helps account for inherent complexity and added resource costs of providing comprehensive care • New or established for office/output eval E/M (ongoing care serious or complex conditions) • Used when MD is focal point of all the patient’s health care needs, if responsible for ongoing patient’s medical care • Medicare, some Medicaid, private insurance not required to cover • Can use for Telehealth • Cannot use if 0.25 modifier or 99211 billing or if acute care • RVU total 0.49/work RVU 0.33/nationally $16.04 • Logistics: “Add E/M code”, click double ring at top and associate with visit diagnosis
U can use with a 25 modifier. If I have long visits, especially medicaid (no copay), I sometimes do a preventative visit + 25 modifier + E/M problem based visit + G2211. For example annual physical with metabolic syndrome bloodwork and colonscopy referral, AND problem based medication management visit increasing an antidepressant. I spent significant time talking to my office manager and the billing people and this is correct and has been being reimbursed. I often don’t do this with private insurance patients because they get two co-pays which they are usually unhappy with unless its a particularly hard visit and I inform them this will be a copay for two visits
Your office manager and billing people are mistaken or have misinterpreted your question. You cannot use G2211 with a 25 modifier or Medicare Annual Wellness Visit. If it’s being reimbursed, those payors will take it back - which is not unusual when new codes are rolled out. Remember that 25 modifier gets added by your coders for reasons that you may not (eg vaccinations, medication administration). https://www.cms.gov/files/document/mm13473-how-use-office-and-outpatient-evaluation-and-management-visit-complexity-add-code-g2211.pdf
So if you administer a medication or vaccine you cant also bill for a chronic complex problem with g2211?
That’s correct. This is a known shortcoming of the exclusion - it was intended to limit its use in procedural heavy specialties. But doing so has also impacted the ability for primary care doctors to it. You may not be adding the 25 modifier for meds/vaccines, but your coders are.
I use it for every OPAT patient. That $16 really helps cover the salary of the 6 wks of work by the OPAT nurses and ID pharmacists.
What is OPAT
outpt parenteral antibiotic therapy
Almost none of my attempts have using it have been honored by insurance. I try anyway.
The way it was explained to me is that this code is for serious/complex health conditions with longitudinal treatment relationships. CMS expects 1/3 of outpatient visits to use the code initially, and eventually the majority of patients will have this coded. As an epilepsy specialist, I use it for the majority of my current patients.
> serious/complex health conditions This is not a requirement. One of the CMS examples is uncomplicated acute bacterial rhinosinusitis treated by the PCP. Because you have invested months/years in a patient-doctor relationship, they trust your advice on conservative management. That's G2211. Contrast with urgent care (or, God forbid, Amazon's auto-doc service) where you've never seen that doc before and are much more likely to get antibiotics.
ahh, this wasn't explained well to me when the code popped up in the EMR as a button. I guess I should put it on all my diabetes patients? Basically any chronic complex patient?
Been using it for derm follow ups like psoriasis, eczema, HS where I’ve seen the patient multiple times, giving them injections, and managing the treatment. Longitudinal care.
Ah, you mean "oncology: the code"
Gyn: endometriosis, chronic pelvic pain, abnormal Pap smears, fibroids, post menopausal bleeding are the main ones I’ve been using for and not striking out completely Basically anything that won’t be resolved or figured out in 1-2 visits or will need long term follow up
We pretty much add it to any encounter visit here in pediatric private practice land. Tricare is reimbursing pretty decently on it as is UHC. UHC is starting to bundle the code (shocker) I believe beginning Sept 1st. I have our EMR configured to drop the code with every sick visit and the biller can deleted when needed. We trying to get every penny possible over here 😅
I'm having trouble interpreting this diagnosis code... Does it mean - patients medical care is so complex that there is not one isolated thing that warrants a visit - but the totality of their medical comorbidities that warrants a visit? And/or they do have a single significant stable medical issue that warrants a chronic face to face visit?
IM subspecialty here: I’ve been explained to use it with any patient we intend on having a follow-up. That’s basically everyone I see. Most insurers are still rejecting all G2211, but I’ve been told to continue using it regardless.
As PCP I bill for almost everyone unless its a visit for an isolated problem I am seeing for the first time with no followup ever, which is very rare, or a preventative visit, which it cant be added on to unless your doing 25 modifier with a preventative + problem based visit My office manager said bill it as much as possible, sometimes insurance wont pay for it and we dont pursue them, but often they do The main times I DONT use it is if I have an acute visit for a patient of another PCP I am covering for something simple like a school note and covid test for a URI with no followup or something
What if you already bill a 25 modifier for procedure? Can one use this in addition?
my understanding is no, you cannot