Confusion Reigns over Application of G2211

Although the effective date for billing Office and Outpatient (O/O) Evaluation and Management (E&M ) Visit Complexity Add-on Code G2211 was Jan. 1, the Centers for Medicare & Medicaid Services (CMS) published a later date of Feb. 19.

What exactly does this mean?

Well, if you have billed this code and received a denial or rejection from your Medicare contractor, perhaps you may want to rebill the service. If you were one of the many organizations that held off from billing it out of fear of code description ambiguity, lack of documentation guidance, or something else… well, perhaps now is the time to test the waters.

Here is where we are today.

CMS held an Open Door Call on Jan. 24. During that call, CMS attempted to shed some light on some of the lingering questions stakeholders had about this code. CMS advised that G2211 could be billed on a new patient encounter once the intent was evident that the provider was working to establish a long-term relationship with the patient. CMS also clarified that more than one provider (e.g., a bone marrow transplant team) may bill this code when each provider is responsible for a portion of the patient’s longitudinal care.

Questions abound over G2211 can be billed when a prolonged service (e.g., G2212, 99417, etc.) code is billed; it remains a mystery. At this point, we also may not be fully aware of how Medicaid and private payers will handle this code. Some of my colleagues have reported receiving denials from a commercial carrier with a denial reason of “per CMS, G2211 cannot be billed when any other service is billed.” This is absolutely erroneous and ripe for appeal. CMS guidance is clear that G2211 should not be billed when the O/O E&M code is billed with Modifier 25. However, denying a claim where G2211 is billed with, let us say, a lab service, is wrong.

Here is what you should do when implementing this service:

• Analyze if this service is appropriate for your specialty;
• Create an internal policy for proper documentation capture and billing;
• Update your charge description master or billing software to capture this service;
• Furnish provider education; and
• Create an audit process for this service (it is a best practice to review/audit any newly provided service).

This service is not a free-for-all! Every provider, every setting, and every patient encounter will not qualify; however, many will. Do not lose sight of the intent for this code (to reimburse providers for work involved in providing a longitudinal relationship with patients, all in an effort to build trust, improve care, and promote better treatment outcomes). CMS has promised a FAQ on this code.

We have not seen that released yet, but Palmetto GBA will be hosting a webinar on this topic on March 28. If you are under this Medicare Administrative Contractor (MAC), it may be worth attending.