With the recent introduction of HCPCS code G2211, there has been much speculation on its proper use and how to implement it compliantly. What it has done is create an opportunity to help physicians improve the physician-patient relationship.
How significant is it?
Understanding the Significance: G2211 represents more than just another addition to our coding books; it creates an opportunity for accurately documenting the patient’s story. As specialists in this field, their ability to grasp its importance and implement this code is essential for maximizing its potential impact on their organization.
The focus is and should be on connecting the cognitive workload of the physician and the needed management of the condition in question or the inherent complexity that is associated with managing the patient’s care for all needed services stemming from a particular encounter.
Implementing G2211 requires a diligent approach to documentation. The responsibility lies with the physician in capturing the full picture that will shape the management of the patient encounter, emphasizing specific elements outlined in the code description.
So, what are the specific elements? Let’s take a look at the full Description and dissect it:
G2211: 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)
First, it’s important to note the two-part description separated by the term and/or. This terminology is often overlooked by those reporting codes and needs to be highlighted as a key in clarifying the intent of this code. The point of the first part of the description appears to be highlighting as we expect that specific visit in question.
The documentation should reflect the cognitive load required for the physician to address the complex nature of providing ongoing care to the patient.
The second part of the description after the and/or reflects the condition itself being serious or complex. Some conditions are very complex and need to be singly cared for which requires ongoing management and will require a long-term solution developed over time between the physician and the patient.
Some specialty societies have pushed back on the concept of a longitudinal relationship but we must remember that CMS is the one who created this code and they specifically use the term “Longitudinal” in their guidance document where they state “G2211 captures the inherent complexity of the visit that’s derived from the longitudinal nature of the practitioner and patient relationship”. Keep in mind that in some cases it’s the relationship and not the condition itself that is part of the equation as in the first part of the description we discussed above.
Management with Specialty Care
In the guidance CMS provided, they also made it clear that this code is not limited to a particular specialty but would still need to be used in the manner intended as described in the description above. It is very valuable for specialists because in recent times it is very popular for a patient to bypass Primary Care altogether and have a specialist manage a condition.
If the specialist such as an Otolaryngologist is managing a condition that requires developing and maintaining a long-term relationship to manage the complexity of a particular visit over time or they have a single complex condition they are taking responsibility for then they have every right to report this code as long as it is reported correctly.
It is needed for us to balance the payer guidelines in this code with the clinical expertise of Physicians who are managing the care and get their thoughts. CMS is allowing physicians to express the workload as they should. Check out what some are saying in Otolaryngology and Ophthalmology that will help you implement G2211 while balancing payer compliance.
If you are working in the field of Podiatry, something to consider is the many conditions specific to podiatry that are managed long-term term such as Diabetic Neuropathy, which usually affects the feet and legs. So although diabetes is managed by the PCP in many cases, the complexity of the neuropathy in the foot takes on a unique challenge for Podiatrists and patients will usually manage this condition directly with their Podiatrist. There is also Chronic Degenerative joint disease that many patients go directly to their Podiatrist to manage.
Billing Requirements
To report G2211 correctly we must note that it is designed as an add-on code to Evaluation and Management code ranges 99202-99215 as indicated in the final part of the code description (list separately in addition to office/outpatient evaluation and management visit, new or established)
As noted, you can also see it is available to use for New or Established visits which again goes back to the two-part description, meaning you establish the relationship with your plan of care and then maintain it showing the progress and cooperation of the patient with the care plan for the condition that was established at the onset that carried complexity necessitating the management to ensue.
It was mentioned in the Official Guidance by CMS that it would not be appropriate to use this add-on code when a Modifier 25 is also used on the primary EM with a minor procedure.
This is also something highly debated with specialty societies and Primary Care society AAFP made some very good points regarding the restriction of G2211 with Modifier 25 on the EM. Limiting its use should be encouraged but it should still be allowed instead of completely denied. The hope is that outreach from societies will show the various circumstances where Modifier 25 and G2211 would be appropriate.
I would also on the other side of things like to point out that if the visit is focusing on the short-term nature of resolving a condition with a minor procedure that will not result in a long-term relationship and the complex cognitive workload is not established, then CMS is within its right to only pay for the minor procedure and E/M but not the addition of G2211.
At present, there are no specific documentation requirements other than establishing medical necessity based on the guidelines already identified in their guidance document. CMS wants to see the cognitive work established plain and simple.
They have stated that their reviewers will consider:
· Information included in the medical record or the claim’s history for a patient/practitioner combination, such as diagnoses
· The practitioner’s assessment and plan for the visit
· Other service codes billed
We encourage practices to be ready to make a defense for their use by clear and comprehensive documentation. If after receiving payment, CMS claws back on those payments made after a review, please take due diligence in responding to such requests with a clear appeal and support of why you reported the service.
In the interim, it is advised to have a workflow and audit system in place to review the use of this code with your coding and billing teams as well as quarterly audits by consulting auditors trained to respond to payer denials such as these.
Being intentional with the new HCPCS code G2211 is crucial! Let’s embrace this new code with a commitment to the patient-physician relationship, with collaboration and communication at the core and continuous improvement, setting a standard for intentional and impactful coding and reporting of our services.