Physicians can now report E/M complexity add-on code G2211 with certain Medicare Part B preventive services
HCPCS code G2211, which became payable January 1, 2024, is designed to capture the complexity and additional resource costs associated with evaluation and management (E/M) services. More specifically, it allows physicians to bill for work related to continuous relationship-based care when they serve as the continuing focal point for all the patients’ healthcare services needs and provide ongoing medical care related to a patient’s single, serious condition or complex condition. In terms of 2025 G211 reimbursement, E/M complexity add-on code G2211 pays a national average payment of $15.53 with a work relative value unit of 0.33.
G2211 reimbursement updates
We wrote about G2211 when it first became payable last year, stating it could even help generate revenue and even enhance the doctor-patient relationship. Now there are G2211 reimbursement updates to provide as well. More specifically, there are new opportunities to bill this code starting January 1, 2025 thanks to changes finalized in the calendar year 2025 physician fee schedule final rule and a recent transmittal published in December (Transmittal 13015).
Here’s a recap of what you need to know about these important changes related to G2211 reimbursement:
1. You may be able to report E/M complexity add-on code G2211 when you provide certain Part B preventive services on the same day. These services include annual wellness visits, vaccine administration, or any Medicare Part B preventive service furnished in the office of outpatient setting. See Attachment A of Transmittal 13015 for a complete list of these services.
CMS’ rationale for the change? In Transmittal 13015, the agency states the following:
In part, the visit complexity add-on code recognizes the inherent costs of building trust in the practitioner-patient relationship. We believe that trust-building in the longitudinal relationship is more significant than ever in making decisions about the administration of immunizations and other Medicare Part B preventive services.
2. E/M complexity add-on code G2211 isn’t payable when you report the associated E/M visit (codes 99202-99205, 99211-99215) with modifier -25.
3. There are no restrictions in terms of specialties that may report G2211. All medical professionals who can bill office and outpatient E/M visits may also report G2211. For example, an infectious disease physician could bill G2211 when they are part of ongoing care for a patient with HIV (a single, serious condition and/or complex condition). The same is true for a practitioner who is part of ongoing care for a patient with sickle cell disease. However, the provider billing G2211 must meet all billing requirements before submitting the code. Here’s a CMS FAQ about G2211 that describes these requirements in detail. In addition, Medlearn Matters (MM) article 13473 provides several examples of how to determine whether you are the focal point for a patient’s healthcare needs.
4. CMS doesn’t require specific documentation for E/M complexity add-on code G2211, but it does state the following in MM13473:
You must document the reason for billing the O/O E/M visit. The visits themselves would need to be medically reasonable and necessary for the practitioner to report G2211. Also, the documentation would need to illustrate medical necessity of the O/O E/M visit. We haven’t required additional documentation. Our medical reviewers may use the medical record documentation to confirm the medical necessity of the visit and accuracy of the documentation of the time you spent.
CMS considers the following details supporting documentation for billing code G2211:
Information included in the medical record or in the claims history for a patient/practitioner combination, such as diagnoses
The practitioner’s assessment and plan for the visit
Other service codes billed
How to leverage E/M complexity add-on code G2211 correctly
There are several steps your medical practice can take now to implement these changes and ensure accurate G2211 reimbursement. Consider the following:
Educate your staff about G2211 reimbursement. Ensure physicians and medical coders both understand when it is—and isn’t—appropriate to report G2211 with modifier -25 and an E/M visit.
Identify potential missed revenue opportunities. Review the list of Medicare Part B preventive services with which you may bill G2211 to determine whether it makes sense to routinely assess whether E/M complexity add-on services may be billable with certain other preventive services.
Develop a strategy to collect the patient copayment or deductible. The usual Part B patient coinsurance and deductible applies when HCPCS code G2211 is billed.
Monitor denials. You could see a denial for G2211 if the underlying E/M visit is denied. CMS encourages providers to consult their Medicare Administrative Contractor as well as the agency’s E/M services guide (MLN006764) regarding E/M documentation.
Explore G2211 reimbursement
Now that it’s possible to report E/M complexity add-on code G2211 with certain Medicare Part B preventive services, it’s in your best interest to explore potential revenue opportunities for your medical practice. Pursuing these and other revenue-boosting strategies can promote financial sustainability. Learn how edgeMED can help.
References
https://www.cms.gov/files/document/r12461cp.pdf
https://www.cms.gov/files/document/r13015otn.pdf
