Medicare’s G2211 and thoughts on how to best use it in urology

Jonathan Rubenstein, MD

Medicare has finally instituted their add-on Healthcare Common Procedure Coding System (HCPCS) code G2211 to help what they believe to be an important addition to the reimbursement system: compensating physicians for the extra work required to care for patients with long-term health care needs who are being seen in the office or other outpatient setting. Although this code was supposed to be implemented a few years ago, this code is effective as of January 1, 2024. We have touched on this code in previous coding articles. However, we felt that it was important to again address this topic because we have received numerous questions regarding the correct use of this code and we have had some experience using the code now that it is active and been able to observe some of the initial payment processing by the payer. The Medicare national payment rate is $16.04. We have yet to receive any additional instruction or clarification of appropriate use of this code or to see any other guidelines beyond those initially published in the Federal Register for the Medicare final rule. We expect that with the questions generated, we will see some additional guidance from Medicare at some point in the future.

Mark Painter

As a reminder, the HCPCS G2211 add-on code descriptor is the following:

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)

In the final rule, Medicare clarified that the patient-physician relationship is the primary consideration that will drive reporting of the code in addition to the evaluation and management (E/M) visit. They have further clarified that if the E/M code reported on the same date of service requires the use of modifier 25 (for example if a procedure is performed) that the additional resources of the procedure adequately reimburses the provider for the extra work required for long-term care already and therefore G2211 is not going to be additionally reimbursed.

Based on the available Medicare rules and the description, we are recommending the following:

• Do not report G2211 on dates of service for which modifier 25 should be appended to the E/M code.

Note: For urology office visits, please remember that Current Procedural Terminology codes 51741 (uroflow) and 51798 (postvoid residual [PVR]) are XXX global codes and therefore do not require modifier 25 to be appended to the E/M service reported on the same date. Therefore, it is appropriate to report code G2211 (if it meets criteria) along with uroflow and/or PVR at the time of an outpatient E/M visit if medically necessary.

• Do not report G2211 unless an E/M code is reported for the same date of service.

Note: G2211 is an add-on code for office or other outpatient E/M visits.

• Do not report G2211 for an encounter with a patient who is not under your ongoing care for a separate, single serious or complex condition for a problem that is transient or potentially transient in nature (eg, initial visit with flank pain, urinary tract infection [UTI], stone, etc).

Note: This would not meet the definition of G2211.

• Do not report G2211 for encounters with patients to whom you are rendering a second opinion for a single serious or complex condition and for whom you do not assume care for the condition.

Note: This would not meet the G2211 definition.

• Do not report G2211 for encounters with those patients for whom you are providing directed services targeted at a single complex problem but not intending to provide the long-term care for the problem (eg, patients referred for robotic prostatectomy under the direction of another physician who is not a part of your practice).

• Report code G2211 if seeing a patient for and reporting an office or other outpatient E/M service in which you are managing total patient care for single or multiple serious or complex conditions (eg, benign prostatic hyperplasia, cancer of any type, incontinence, renal cyst, recurrent UTI, recurrent stones, etc).

• Report code G2211 if reporting an office or other outpatient E/M visit for a patient with a transient or temporary problem (eg, UTI, stone, flank pain, etc) if you have an established relationship with the patient for whom you are providing ongoing longitudinal care for a single serious or complex condition, even if it is unrelated or potentially related to the transient problem being treated.

We would recommend the following documentation to support the reporting of code G2211:

• Documentation for an E/M visit focused on care for the total patient requiring ongoing care or ongoing care for a single serious or complex condition should not require additional documentation specific to the code but should include clear direction and a care plan demonstrating patient return and continued care for the patient and/or condition.

• Documentation for an E/M visit for which the focus of the visit is unrelated or not obviously related to the treatment of the total patient or the treatment of the single serious or complex condition should include additional documentation indicating that the patient is returning to the practice for care directed at the single serious or complex condition at a future visit in addition to the appropriate documentation for the services rendered on that date.

Telehealth and telephone-only visits would also qualify for the add-on code. Both Medicare and Medicare Advantage (MA) plans are processing the G2211 code for payment. However, we have found that some MA plans are requesting that modifier 59 be appended to the G2211 code for processing purposes.

Finally, for billing purposes, we would encourage you to reference the International Classification of Diseases, Tenth Revision code for the single serious or complex position in the primary position for code G2211 even if the primary diagnosis for the E/M code provided is for a different problem on the date of service. We remind you that this is our interpretation at this time, and we expect additional guidance to be issued by Centers for Medicare & Medicaid Services in the future.

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o Urology Times®, at UTeditors@mjhlifesciences.com.

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.