Effective, January 1, 2024, CMS finalized changes for HCPCS G2211 to make it separately payable by assigning it an “active” status indicator. HCPCS G2211 includes services that enable practitioners to build longitudinal relationships with all patients (that is, not only those patients who have a chronic condition or single, high-risk disease) and to address most patients’ health care needs with consistency and continuity over longer periods of time. This includes furnishing services to patients on an ongoing basis that results 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. The “continuing focal point for all needed health care services” describes a relationship between the patient and the practitioner when the practitioner is the continuing focal point for all health care services that the patient needs.
This code is not restricted to medical professionals based on specialties. Instead, it should be used by medical professionals, regardless of specialty, with office/outpatient (O/O) evaluation and management (E/M) visits of any level for care that serves as the continuing focal point the center or interest 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.
Medicare/Medicare HMO claims will deny when HCPCS G2211 is not billable with services reported with a -25 modifier or when services are performed in a Method 11 Critical Access Hospital on the same encounter for type bill with 85X.
Layman terms: HCPCS G2211 is an add-on code to office and other outpatient services, which represents the communication regarding the patient’s condition, treatment in a way that allows open communication between provider and patient that is safe while building trust. Visits should be reported with E/M codes 99202-99205 and 99212-99215 without the use of – modifier 25. Payable by Medicare and Medicare HMO’s. May not be payable by Medicaid, Medicaid HMO’s or Commercial payers. HCPCS G2211 is not payable when modifier 25 is used for office outpatient visits.
Applies to Provider Types: Physicians, Nonphysicians practitioners who bill Medicare Administrative Contractors (MAC’s) for office outpatient evaluation management services they provide to Medicare patients.
Specialties: All office outpatient providers regardless of specialty.
Applicable year: 2024
Location: Office/Outpatient
Example: a patient with HIV has an office visit with their infectious disease physician, who is part of ongoing care. The patient with HIV admits to the infectious disease physician that there have been several missed doses of HIV medication in the last month. The infectious disease physician has to weigh their response during the visit —the intonation in their voice, the choice of words—to not only communicate clearly that it is important to not miss doses of HIV medication, but also to create a sense of safety for the patient in sharing information like this in the future. If the interaction goes poorly, it could erode the sense of trust built up over time, and the patient may be less likely to share their medication adherence shortcomings in the future. If the patient isn’t forthright about their medication adherence, it may lead to the infectious disease physician switching HIV medicines to another with greater side effects, even when there was no issue with the original medication. It is because the infectious disease physician is part of ongoing care, and has to weigh these types of factors, that the E/M visit becomes inherently more complex, and the practitioner bills this code (G2211). Even though the infectious disease doctor may not be the focal point for all services, such as in the previous example, HIV is a single, serious condition and/or a complex condition, and so as long as the relationship between the infectious disease physician and the patient is ongoing, this E/M visit could be billed with the add-on Billable code 99212-99215 and G2211.
