Updates to G2211

Are your providers billing G2211 correctly? AMA estimated a 30% use in this code, when it was introduced, but the reported use of the HCPCS code in 2024 was much higher at 89% usage.

In 2024, the Centers for Medicare & Medicaid Services (CMS) introduced HCPCS code G2211, an add-on code for office and outpatient evaluation and management (E/M) services. This code is designed to capture the inherent complexity of visits that arise from the longitudinal nature of the practitioner-patient relationship. It applies when a healthcare provider serves as the continuous focal point for all of a patient's healthcare needs or provides ongoing care for a single, serious, or complex condition.

HCPCS code G2211 is reported in addition to the primary E/M service codes (CPT codes 99202-99205 for new patients and 99211-99215 for established patients). It is not restricted to any specific medical specialty and can be utilized by all healthcare professionals who bill Medicare for office or outpatient E/M services. However, G2211 should not be reported without an associated E/M base code and is not applicable in situations where the patient-practitioner relationship is limited or episodic. For example, it would not be appropriate for a one-time consultation or treatment of an acute, uncomplicated condition.

In 2025, the Centers for Medicare & Medicaid Services (CMS) implemented significant updates to HCPCS code G2211, enhancing its applicability and reimbursement policies.

Expanded Use with Modifier 25:

Starting January 1, 2025, CMS allows the reporting of G2211 in conjunction with office or outpatient evaluation and management (E/M - 99211-99215 & 99202-99205) services that include modifier 25. This expansion applies when the additional service is a Medicare Part B preventive service, such as:

• Initial Preventive Physical Examination

• Annual Wellness Visit

• Vaccine administration

This change acknowledges the added complexity in managing patients' preventive care needs alongside other E/M services.

Documentation Requirements:

Providers must document the medical necessity of both the primary E/M service and the complexity represented by G2211. This includes detailing the provider’s assessment, care plan, and any other relevant information that supports the use of the code.

These updates aim to better recognize the complexity of primary care services, ensuring appropriate compensation for providers managing patients’ overall health needs.

Do you or your providers need help? Visit www.triumphmps.net or call 214-305-8805 so our experienced consultants can help.