G2211 (add-on code) covered by Medicare and Commercial Insurances

HCPCS Code 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 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).

What we know so far?

It can be billed with office or other outpatient E/M services 99202-99205 and 99211-99215. It is intended to reimburse for the increased resources associated with the complexity of care and cognitive load required by providers who furnish consistent and continuous services for a patient’s overall healthcare or that of a single serious or complex condition. (e.g., a family medicine PCP managing multiple conditions over time, an endocrinologist managing care for type 1 diabetes with complications, an oncologist managing care for cancer, etc.)

  • It is not limited by specialty.
  • CMS will reimburse $16.04 for G2211 starting 01/01/2024.
  • It was added to the CMS Approved Telehealth services list.
  • The code is not tied to clinical conditions but rather the overarching “longitudinal” relationship between provider and patient.

When can it be billed (with proper support)?

When the E/M visit documentation supports an ongoing, comprehensive, continuous longitudinal relationship between the provider and patient where the provider has assumed responsibility for the overall management/coordination of the patient’s healthcare.

When the E/M visit supports ongoing care for a single, serious, or complex condition such as HIV, sickle cell disease, etc.

When should it NOT be billed?

  • When there is no E/M on the same date of service.
  • When there is a lack of medical necessity documented.
  • When there are other procedures (ie injections or tests) billed the same day.
  • When there is a lack of proper support for either the longitudinal relationship between provider and patient or the ongoing care of a single serious or complex condition(s).
  • When acute visits are for conditions of a transient nature unless the provider has also assumed care for the patient’s overall healthcare management over time (with supportive documentation).
  • When visits are only of a discrete, routine, or time-limited nature, e.g., laceration, common cold, UTI, fracture, and other transient conditions.
  • When comorbidities are not present (or addressed) and/or when the billing provider has not assumed responsibility for the patient’s ongoing healthcare.

 

Which Insurance is covering this HCPCS code?

  1. Medicare *effective from date: 01/01/2024
  2. Humana [Commercial and Medicare advantage plan] *effective from date: 03/01/2024
  3. Cigna [Medicare advantage only] *effective from date: 03/01/2024
  4. United Healthcare [Commercial and Medicare advantage plan] *effective from date: 03/01/2024

Other Payers or line of business have not confirmed. We will notify our providers if there is a new update.