Evaluation and Management

Office/Outpatient Evaluation and Management Visit Complexity Add-on Code G2211

Effective 1/1/2024

Definition of 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 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).

Billing Information

Payment for G2211 is allowed when CPT codes 99202-99205, 99211-99215 (O/O E/M base code) are billed by the same physician or nonphysician practitioner, on the same date of service, for the same patient.
This may be for new or established patients.
No modifier is required.
Relationship between the patient and the practitioner is the determining factor of when the add-on code should be billed, it is not based on the characteristics of a particular patient.

Effective 1/1/2025, payment for G2211 is allowed when CPT codes 99202-99205, 99211-99215 (O/O E/M base code) are billed by the same practitioner on the same day as an AWV, vaccine administration, or any Medicare Part B preventive service, including the IPPE.

In all other cases where an O/O E/M visit is reported with payment modifier 25, G2211 will not be paid.

Key Components

The relationship between the patient and the practitioner is the determining factor of when the add-on code should be billed.
Code G2211 will identify the inherent costs involved when clinicians are the continuing focal point for all needed services or are part of ongoing care related to a patient’s single, serious condition or a complex condition.
Primary care specialties will have a higher utilization than other specialties. However, G2211 is not restricted to medical professionals based on a particular specialty.
G2211 would not be considered duplicative of care management services since the inherent complexity better recognizes the professional work within the visit, while the care management codes recognize services that happen outside of the visit.

ICD-10-CM Code

No specific diagnosis is required for HCPCS code G2211.
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.

Cost Sharing

Part B patient coinsurance and deductible will apply when HCPCS code G2211 is billed.

Documentation

There are no specific additional medical record documentation requirements. Medical review may use the medical record documentation to confirm the medical necessity of the visit and the patient care relationship. We would expect that information included in the medical record or in the claim history for a patient/practitioner combination, such as diagnoses, the practitioner’s assessment and medical plan of care, and/or other codes reported could serve as supporting documentation.
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.

Note: G2211 would not be 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 a patient with consistency and continuity over time.

Examples

A patient has a primary care practitioner that is the continuing focal point for all health care services, and the patient sees this practitioner to be evaluated for sinus congestion. The inherent complexity that this code (G2211) captures is not in the clinical condition itself (sinus congestion) but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.
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.

Reminder: Building an effective longitudinal relationship, in and of itself, is a key aspect of providing reasonable and necessary medical care and will make the patient more likely to comply with treatment recommendations after the visit and during future visits.

Note: It would not be appropriate to report G2211 when the care furnished during the O/O E/M visit is provided by a professional whose relationship with the patient is discrete, routine, or time-limited nature; such as, but not limited to, a mole removal or referral to a physician for removal of a mole; for treatment of a simple virus; for counseling related to seasonal allergies, initial onset gastroesophageal reflux disease; treatment for a fracture; and where comorbidities are either not present or not addressed, and/or when the billing practitioner has not taken responsibility for ongoing medical care for that patient with consistency and continuity over time, or does not plan to take responsibility for subsequent, ongoing medical care for that patient.