Inherent Complexity Code – G2211
We’ve all been waiting for it. Waiting since the 2021 proposed rule. Now that it’s finally here, we aren’t quite sure what to do with it! CMS (Centers for Medicare and Medicaid Services) has given us just enough rope to…well, you know. The guidance they provided for this new HCPCS code is more ambiguous than usual, and that’s saying something! CMS gave us more “what not to do” information, than how to legitimately and accurately report this service. Let’s start by taking a look at the code description (below).
What we know.
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)
The first part, I get. Describes a primary care relationship. The and/or part, is where it gets a bit tougher to define. There’s a key phrase in Transmittal 12461 that gives a little more clarity, but not much.
“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.
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.
The most important information used to determine whether the add-on code could be billed is the relationship between the practitioner and the patient.”
What else do we know?
CMS has not really given any hard and fast rules about documentation. They will be looking at the patient record for ongoing, longitudinal care, as mentioned above.
What you cannot do!
What you may not do, is report G2211 with an E/M that has a procedure on the same day. CMS will deny any G2211 on claims with a -25 modifier appended. CMS estimates that G2211 will be submitted on 90% of primary care E/M claims, and 38% overall for E/M coding submitted across all specialties.
We will be watching and waiting for further clarification from CMS. Until then, we have also provided additional resources below.
Resources:
MedLearn Matters article relating to Transmittal 12461
AAFP – Info Graphic, articles What it is and how to use it and Decoding G2211 Myths
MSHBC G2211 Documentation Tips
UTH CDI G2211 Tip Sheet