Otolaryngology Coding Alert

Question: Where do things stand with the implementation of add-on code G2211, and why is there so much controversy surrounding this code?

New Mexico Subscriber

Answer: The Centers for Medicare & Medicaid Services (CMS) has finally decided to make add-on code G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all … ongoing care related to a patient’s single, serious condition or a complex condition …) effective in 2024. The additional payment for the visit complexity add-on code aims to better recognize and account for the inherent costs clinicians may incur when longitudinally treating a patient’s single, serious, or complex chronic condition.

History: HCPCS Level II code G2211 was originally proposed three years ago, but due to pushback related to the potential payment reduction certain specialties would face, Congress delayed the implementation of the code. However, since this policy was finalized in 2021 and was simply delayed until calendar year (CY) 2024, the policy will go into effect without any further action on Jan. 1, 2024.

Refinements to the G2211 policy include:

1) A proposal not to pay for G2211 when simultaneously billed with an office/outpatient (O/O) evaluation and management (E/M) visit that has payment modifier 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure …) appended.

2) An adjustment of the utilization estimate for G2211 from 90 percent of O/O E/M visits billed by certain physician specialties (roughly 58 percent of all office visits) to instead being billed with 38 percent of all O/O E/M visit claims initially, But in several years, when G2211 is fully adopted, CMS predicts the HCPCS Level II code will be billed with 54 percent of all O/O E/M visits.

Despite these revised utilization assumptions CMS is proposing, G2211 continues to drive a significant payment reduction to the PFS overall for CY 2024. Specifically, the agency notes that approximately 90 percent of the -2.17 percent budget neutrality adjustment to the CF for CY 2024 is attributable to G2211, with all other proposed valuation changes making up the other 10 percent.