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Complex and Chronic Care - HCPCS Code G2211
- Please define appropriate usage and billing for HCPCS code G2211.
Answer: CMS has approved G2211 for 2024 as an add-on code for complex and/or continuous office and outpatient E/M services (99202-99205 and 99211-99215). The exception is that G2211 may not be used when modifier 25 has been added to the E/M service on a claim.
To confirm the necessity of adding modifier 25 to an E/M service, the provider may access the appropriate CMS NCCI) table at CMS’ Medicare National Correct Coding Initiative (NCCI) Edits web page.
If you enter the code you want to add to the E/M claim in Column 1 (e.g., CPT 93000), you will see in Column 2 all the E/M services that require a modifier 25 if this code is added to the claim. The code will have an NCCI Indicator of 1, meaning it requires addition of modifier 25 to the E/M service.
For additional clarification on appropriate use of modifier 25, please see Modifier 25 and FAQ number one under Separately Identifiable Services.
- Please define the meaning of “longitudinal relationship” in relation to G2211.
Answer: Based on recent CMS guidance, the term “longitudinal” in reference to G2211 means that the provider, whether in a new or subsequent episode of care, is establishing or continuing a relationship with the patient that is expected to be of significant duration. The reasons for the expected continuation of care may include the context of a primary care setting or may apply to specialty care for a serious or complex condition, that will be provided over an extended period. An isolated service to address a simple or self-limiting condition would generally not qualify as longitudinal care.
G2211 may be used for new patient visits when it is expected that additional visits to treat or follow the patient’s condition(s) will be necessary.
- Please explain any limitation on the type of provider who may consider use of G2211 with E/M service.
Answer: G2211 may be added to claims for E/M services by all provider types (physicians and NPPs) who are currently permitted to perform and bill for E/M services.
- Please define the E/M CPT services with which G2211 may be used.
Answer: As of 2/1/2024, CMS has limited use of G2211 to claims for E/M services 99202-99205 and 99211-99215. Inclusion of other correlative E/M services will be defined here as per any further CMS updates.
- Please define a situation in which G2211 may be used with E/M 99211, which does not require personal physician participation.
Answer: G2211 may be used with 99211 when the service performed is part of a longitudinal period of care for a complex or chronic condition. So, for example, a blood pressure check by an office nurse, in the context of a course of care for uncontrolled hypertension, may warrant G2211.
- Please define any limitation on the frequency or duration at which G2211 may be added to E/M claims.
Answer: There are no frequency or duration limitations on G2211. Medical necessity is the primary factor in considering the use of this code; the medical record must support the key elements of the code’s definition and requirements.
- Please define the POS limitations for G2211.
Answer: G2211 usage is limited to claims for E/M services performed in the office (POS 11) and outpatient (POS 19 and POS 22) settings. G2211 may also be added to audio/visual telehealth claims for CPTs 99202-99205 and 99211-99215 when performed with POS 02 and POS 10.
- Is G2211 permissible on claims for E/M services performed by residents in the PCE setting?
Answer: A resident’s E/M service in the PCE setting is limited to CPTs 99202-99203 and 99211-99213. The service requires either personal or direct supervision by a teaching physician as the provider. G2211 may be added to the claim when medically appropriate. Please note that modifier GE may not be added to G2211. - May G2211 be added to an E/M claim on which a prolonged service code has also been included?
Answer: CMS has not precluded use of G2211 on an E/M claim that includes a prolonged service code. These add-on codes represent different facets of a given service. The prolonged service code defines additional time needed to complete an E/M service, which does not necessarily represent the complexity of the service. The G2211 does reflect complexity of care for chronic or serious conditions and is not related to time spent in the service.
- Is G2211 payable when services 99202-99215 are performed via telehealth?
Answer: Yes, G2211 may be payable when any of the above services are performed via telehealth.
- Is G2211 payable to a provider who is also performing chronic care management services for the same patient?
Answer: Yes, G2211 is payable for patients also receiving chronic care management services.
- May G2211 be billed with E/M services performed on an incident to basis?
Answer: Yes, this is permissible.
Revised 4/17/2024