CMS Releases New FAQs on Complexity Add-on Code (G2211), Including Use by Specialists

The G2211 refers to ((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-in code, list separately in addition to office/outpatient evaluation and management visit, new or established)).

Continued confusion over the appropriate use of the G-code prompted several organizations to request more guidance from CMS. At the end of last month, CMS finally released a new guidance document, Frequently Asked Questions (FAQs) About Office/Outpatient (O/O) Evaluation and Management (E/M) Visit Complexity Add-On HCPCS Code G2211, providing clarifying information on the use of the add-on code. The document makes clear that the code may be used by specialists. G2211 is available for all medical professionals who can bill Medicare for Office and Outpatient (O/O) E/M visits and, for specialists, when the practitioner is “providing ongoing care for a single, serious condition or a complex condition.” However, the code “would not be appropriately reported . . . when the care furnished during the O/O E/M visit is provided by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature.”

For electrophysiologists’ consideration of the use of the code for certain visits, HRS also highlights the guidance provided under Q8 and Q9:

Q8: What constitutes a serious or complex condition? What diagnosis must be used?
A: No specific diagnosis is required for HCPCS code G2211 to be billed. For the billing practitioner, it would be appropriate to report a health condition that is a single, serious condition and/or a complex condition for which the billing practitioner is engaging the patient in a continuous and active collaborative plan of care related to an identified health condition—the management of which requires the direction of a practitioner with specialized clinical knowledge, skill, and experience. Such collaborative care includes patient education, expectations and responsibilities, shared decision-making around therapeutic goals, and shared commitments to achieve those goals. We provide several examples to clarify the use of HCPCS code G2211 in the context of specialty care. For example, HCPCS code G2211 could be billed by an infectious disease physician who is part of ongoing care for a patient with HIV (a single, serious condition and/or complex condition), or a practitioner who is part- of ongoing care for a patient with sickle cell disease.

Q9: What is the definition of “longitudinal”? Does it matter if the patient comes in once a year, every other year, or every 5 years, as long as the patient has selected that physician as their primary care doctor and who they call when they need care?
A: The add-on code HCPCS code G2211 captures the inherent complexity of the visit that is derived from the longitudinal nature of the practitioner and patient relationship. Therefore, HCPCS code G2211 is not appropriate when the billing practitioner has not taken responsibility for ongoing medical care for a given patient with consistency and continuity over time, or does not plan to take responsibility for subsequent, ongoing medical care for that particular patient with consistency and continuity over time. No specific definition is provided for “longitudinal” for HCPCS code G2211 to be billed. As long as the practitioner-patient relationship aligns with Q1 above, HCPCS code G2211 can be billed to recognize the services that enable practitioners to build longitudinal relationships with their patient and address the majority of patient’s health care needs with consistency and continuity over longer periods of time. This includes furnishing services to patients on an ongoing basis that result in care that is personalized to the patient. The services result in a comprehensive, longitudinal, and continuous relationship with the patient and involve delivery of team-based care that is accessible, coordinated with other practitioners and providers, and integrated with the broader health care landscape.