Decoding the Enigmatic Code G2211

Decoding the Enigmatic Code G2211

Back in September 2023, the Centers for Medicare & Medicaid Services (CMS) announced release of an MLN to better equip providers with documentation guidelines in support of the code G2211. 

On Jan. 18, 2024, CMS issued MM13473 entitled: How to Use the Office and Outpatient Evaluation and Management Visit Complexity Add-on Code G2211. The MLN reinforces two main takeaway points: (1) the continuing focal point for all the patient’s healthcare service needs and (2) ongoing medical care related to a patient’s single, serious condition, or complex condition.

The MLN provides a couple examples, the first is a patient managed by their primary care physician (PCP) for sinus congestion. Many scoffed at that example because it does not appear to meet the complexity described in the code’s definition. However, CMS explains, “The complexity that code G2211 captures isn’t the clinical condition of sinus congestion, but rather the complexity around the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.”  The go on to state “even for a simple condition like sinus congestions, the cognitive effort in the longitudinal relationship between the patient and provider in identifying the diagnosis and developing a care plan makes the interaction inherently complex.”

The second example provided by CMS is a clinical scenario in which the patient has a diagnosis of HIV. In this example, the patient has missed a couple appointments, and the provider stresses the importance of keeping those appointments and adhering to the treatment plan in place to receive the desired treatment outcomes. The provider works to build trust with the patient in hopes of the patient adhering to the plan in place.  This example is a very good in describing the intent of the code, the complexity of managing the condition, and the importance of building a longitudinal relationship.

The MLN lists three bullet points that could serve as supporting documentation for billing: (1) information in the medical record or in the claims history for a patient/practitioner combination, such as a diagnosis; (2) the practitioner’s assessment and plan for the visit; and (3) other service codes billed.

I have received numerous questions from colleagues about my thoughts on G2211. I do believe that providers should create an internal policy. Some considerations for that policy may include billing G2211 with new patient codes. Can a provider establish a longitudinal relationship at the point of a new patient visit? It is important to note CMS did not exclude new patient codes 99202-99205.  Another area to cover in an internal policy may be the condition itself.

The increased work effort associated with the continuous care for a serious or complex condition typically involves a chronic condition such as cancer, asthma, and diabetes wherein the side effects of treatment and/or lack of control of the condition may increase the provider’s cognitive load. 

I am not totally excluding conditions that do not meet the definition of chronic, just simply stating providers may need to determine what type of conditions based on their specialty would increase that level of cognitive load to justify billing.

Without a doubt, CMS will be examining claims data to determine the appropriateness based on diagnosis codes and the level of evaluation and management (E&M) submitted. Provider documentation should include the condition(s) addressed on the encounter along with the treatment plan executed or updated. 

Additional documentation to consider would include the goals of treatment, coordination of care with external providers and/or sources, historical data on hospitalizations or care deviation, etc.  Providers should not slap this code on to every E&M  visit. I would recommend implementing a pre-bill audit process to ensure proper code reporting.

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