General Surgery Coding Alert

Hint: Going forward, modifier 25 can be in play.

The road to reimbursement for services provided under +G2211 has been long and bumpy, but the 2025 Medicare Physician Fee Schedule (MPFS) final rule may bring relief to clinicians and practices who have long realized that physicians weren’t always being paid for the full value of the care they provided during some encounters.

Primary care physicians may be especially excited about the forthcoming changes to how +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) may be billed, because beginning in 2025, they may receive additional payment for other significant services rendered on the same day by the same or another qualified healthcare professional.

Reflect on the Past

Beginning Jan. 1, 2024, the Centers for Medicare & Medicaid Services (CMS) adjusted their rules so practices could bill +G2211 for visits pertaining to the evaluation and management (E/M) of some care.

However, according to the American Academy of Family Physicians (AAFP), some family physicians were still having trouble seeking reimbursement for the care they provided because of a caveat in the +G2211 rule that prevented usage of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) with +G2211.

In a March 2024 letter to CMS administrator Chiquita Brooks-LaSure, R. Shawn Martin, AAFP executive vice president and CEO, shared some recommendations for how CMS might better accommodate physicians who provide significant, separate E/M services during otherwise routine visits. Martin said:

“Our recommendation is to allow G2211 payment … when the E/M code has modifier 25 appended to report the following additional, separately identifiable preventive services:

• “Medicare AWV (G0438, G0439) or “Welcome to Medicare” visit (G0402);
• “Immunization administration (90460, 90461, 90471-90474); 
• “Medicare-recommended screening and counseling services, such as:
  • “Q0091 (Screening, Papanicolaou smear)
  • “G0101 (Cervical or vaginal cancer screening)
  • “G0442 (Annual alcohol misuse screening, 5 to 15 minutes) 
  • “G0443 (Behavioral counseling for alcohol misuse)
  • “G0444 (Annual depression screening, 5 to 15 minutes) 
  • “G0446 (Intensive Behavioral Therapy for cardiovascular disease)
  • “G0447 (Behavioral counseling for obesity).”

Martin argued that allowing payment for +G2211 appended with modifier 25 acknowledged the increased complexity and resource usage involved in some primary care visits. He said that “changes to the modifier 25 policy will allow primary care physicians to provide a broad range of comprehensive services during an office visit, consistent with being the ongoing, focal point of care for their patients, which is likely to improve patient outcomes,” and noted that research has suggested that Medicare expenditures are reduced when patients can receive comprehensive primary care.

Use Modifier 25 for Some Services in the Future

In the Calendar Year (CY) 2025 Medicare Physician Fee Schedule Final Rule (MPFS), CMS is making some adjustments to situations in which modifier 25 is appended to some codes, to show that the care the clinician provided extended beyond the E/M service reported. 

In a Nov. 1, 2024 fact sheet, CMS said: “For CY 2025, we are finalizing our proposal to allow payment of the O/O E/M visit complexity add-on code, Healthcare Common Procedure Coding System (HCPCS) code G2211, when the O/O E/M base code — Current Procedural Terminology (CPT) codes 99202-99205 [Office or other outpatient visit for the evaluation and management of a new patient …], 99211-99215 [Office or other outpatient visit for the evaluation and management of an established patient …] — is reported by the same practitioner on the same day as an annual wellness visit (AWV), vaccine administration, or any Medicare Part B preventive service, including the Initial Preventive Physical Examination (IPPE), furnished in the office or outpatient setting.”

CMS Says Forthcoming Modifier 25 Payments Underscore Importance of Primary Care

In the 2025 MPFS final rule, published Dec. 9, 2024, CMS emphasizes their focus on primary care and acknowledges that previous payment rules for +G2211 and the corresponding base E/M codes did not always capture the breadth of care and services provided.

CMS says: “Allowing payment for the O/O E/M visit complexity add-on code in this scenario as proposed would support our policy aims, which include paying for previously unaccounted resources inherent in the complexity of all longitudinal primary care office visits. In part, the O/O E/M 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.”

You can read more about how practices can report +G2211, including when to expect payment for appending modifier 25, here.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC