Within the 2021 Medicare doctor charge schedule remaining rule, the Facilities for Medicare & Medicaid Companies (CMS) added a brand new Healthcare Widespread Process Coding System (HCPCS) code, G2211, as a reimbursable service. This code displays go to complexity and will increase the worth of workplace and outpatient analysis and administration (E/M) companies which might be a part of a affected person’s ongoing well being administration.
G2211
Go to complexity inherent to analysis and administration related to medical care companies that function the persevering with focus for all wanted well being care companies and/or with medical care companies which might be a part of ongoing care associated to a affected person’s single, critical situation or a fancy situation. (Add-on code, checklist individually along with workplace/outpatient analysis and administration go to, new or established)
Goal of HCPCS code G2211
The aim of G2211 is to acknowledge the extra complexity of sure E/M visits, notably when the care supplied by the billing practitioner serves as a focus for all of a affected person’s well being care wants (e.g., main care). It additionally applies when the practitioner manages a single critical or advanced situation over time (e.g., specialist care). This add-on code can enhance reimbursement to account for the additional time, coordination and medical experience required in such instances.
Preliminary delays and implementation in 2024
Though G2211 was initially included within the 2021 doctor charge schedule, its implementation was delayed by Congress by means of the 2021 Consolidated Appropriations Act, which expired Dec. 31, 2023. As of Jan. 1, 2024, G2211 turned a individually payable service below the doctor charge schedule.
Acceptable use of G2211
In response to CMS steering, G2211 is meant for conditions wherein the complexity of care is larger than regular because of both:
Longitudinal care: The practitioner acts as a focus for all well being care companies the affected person requires over time. This state of affairs typically applies to main care suppliers managing persistent circumstances or coordinating varied facets of a affected person’s care.
Administration of a single, critical situation or advanced situation: The practitioner supplies steady and energetic take care of a single, critical situation or a fancy situation that calls for specialised medical information and ongoing administration. This state of affairs is frequent in specialties reminiscent of oncology, the place the supplier oversees the continued therapy of a affected person with most cancers or one other critical sickness.
Practices that ship team-based care can also use G2211 in the event that they function the central level of care coordination for the affected person or present ongoing specialised care.
When G2211 shouldn’t be used
The G2211 code isn’t relevant for conditions wherein the patient-provider relationship is restricted in time or scope. It shouldn’t be used if the supplier doesn’t intend to determine an ongoing care relationship with the affected person. For example, a specialist offering a one-time session or therapy for an acute situation wouldn’t qualify to make use of this code.
Billing tips for G2211
All well being care professionals who can invoice Medicare for workplace and outpatient E/M companies (e.g., CPT codes 99202-99205, 99211-99215) are eligible to report G2211 as an add-on code to those base codes. It’s important to notice that G2211 can’t be billed independently; it should be reported alongside an workplace and outpatient E/M code on the identical day of service.
Capturing complexity and reimbursement
Using G2211 displays the inherent complexity of offering longitudinal care in E/M visits. By doing so, CMS acknowledges the extra effort required to handle sufferers over time, notably these with ongoing or advanced well being care wants.
For 2024, the nationwide cost charge for G2211 is $16.31, with a relative worth unit (RVU) of 0.49. Precise reimbursement charges will fluctuate relying on the situation of the apply, as geographic elements are thought-about in Medicare cost charges.
Instance case
Affected person profile: A 58-year-old man with obstructive sleep apnea (OSA), weight problems, hypertension and persistent insomnia.
Go to purpose: Comply with-up appointment to evaluate the affected person’s response to steady optimistic airway strain (CPAP) remedy, evaluate sleep high quality, and handle related comorbidities.
Supplier actions:
Evaluation of sleep information:
The supplier opinions information from the affected person’s CPAP machine, which signifies inconsistent use and suboptimal outcomes.
The supplier analyzes the affected person’s sleep logs, which present persistent poor sleep high quality and frequent awakenings.
Adjustment of therapy:
As a result of affected person’s stories of discomfort with the CPAP masks, the practitioner discusses totally different masks choices and adjusts strain settings. After a set interval, the practitioner will evaluate how the affected person is doing (through cellphone name, affected person portal message, evaluate of PAP compliance information, and so forth.).
Administration of comorbidities:
The affected person’s hypertension and weight problems are mentioned intimately, as each circumstances contribute to the severity of OSA.
The supplier adjusts the affected person’s antihypertensive medicine because of considerations about hypertension readings, which can be associated to poor sleep.
A weight administration plan is initiated, together with counseling on weight loss program and train.
Coordination of care:
The supplier coordinates care with the affected person’s main care supplier to make sure the up to date hypertension administration is communicated, together with the burden administration plan.
Comply with-up is scheduled with each the sleep supplier and a dietitian.
Billing G2211
On this case, the supplier is managing a number of persistent circumstances (OSA, insomnia, hypertension and weight problems) and fascinating in detailed care coordination and decision-making, which will increase the complexity of the go to past the standard scope of an E/M service. The supplier is eligible to invoice G2211 as an add-on to the first E/M service to replicate the extra complexity and time spent managing these interrelated points.
If the supplier is just managing take care of extreme OSA, G2211 can nonetheless be added to the first E/M service. In sleep medication, this is applicable to different sleep issues that require ongoing care, together with insomnia, RLS, narcolepsy and parasomnias. G2211 will be added to any E/M service, new or established.
G2211 shouldn’t be used if a affected person is seen for a second opinion and a follow-up go to isn’t scheduled, or if a separate billable process is finished on the identical day of the go to with a modifier 25.
Extra documentation justifying the usage of the G2211 code isn’t required presently. Go to documentation for the first E/M service ought to clearly point out that the practitioner is the principle individual managing take care of a single, critical situation or a persistent situation.
An necessary consideration is that sufferers might have copayments and deductibles that apply to the G2211 code since it’s an add-on code for an E/M service, new or established.
Conclusion
HCPCS code G2211 represents an necessary step by CMS to acknowledge the extra complexity of managing sufferers’ ongoing well being care wants. By offering elevated reimbursement for these companies, the code goals to assist practices that ship coordinated, longitudinal take care of a single, critical situation or a fancy situation. As of Jan. 1, 2024, well being care professionals ought to contemplate this add-on code when billing for workplace and outpatient E/M companies to make sure they’re appropriately compensated for the care that’s being supplied.
Members might ship coding questions and use instances they want to have featured within the Coding Quarterly to coding@aasm.org.
