Primary Care Coding Alert

Also: find CMS guidance regarding +G2211 and modifier 25

In addition to the final rule updates mentioned in “Find Four Takeaways From the 2024 MPFS Final Rule” (Primary Care Coding Alert volume 26, number 1), CMS has also made good on its promise to make HCPCS Level II 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 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) active beginning Jan. 1, 2024.

Background: “CMS first proposed code +G2211 in 2021 as a way to compensate physicians for the extra work required for coordination of care for complex or serious conditions. Congress mandated a delay in implementation of the code until Jan 1, 2024,” explains Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel advisor for ASGE in Pasadena, California. “Although CMS received mixed reviews for code +G2211, for various reasons they have elected to proceed with the implementation of the code with the revisions as proposed,” he says.

Some commenters argued there was “a lack of clarity surrounding the appropriate circumstances for reporting the inherent complexity add-on code and that combined with potential implications for patient cost-sharing, health care practitioners would experience ambiguity toward billing the code, which could result in our having overestimated utilization,” the final rule says. Others urged CMS to “align utilization estimates with the actual first year utilization of care management codes for transitional care management (TCM) and chronic care management (CCM)” while some entreated the agency to apply mid-year adjustments to the CF if the agency found it “overestimated utilization of the code,” the final rule highlights.

CMS did take these concerns into account and refined the CY 2021 policy to better accommodate stakeholders and “reduce the estimated redistributive impacts of this policy,” the agency says in a fact sheet on the rule. The fact sheet also states that, starting Jan. 1, 2024:

“The add-on code cannot be billed with an office or outpatient evaluation and management visit that is itself focused on a procedure or other service instead of being focused on longitudinal care for all needed healthcare services, or a single, serious or complex condition.”

• CMS will monitor how the code is being utilized and make refinements if necessary.
• Due to public input, CMS revised utilization estimates and “these modifications reduce the redistributive impact to the CY 2024 conversion factor by nearly one third from the estimated impact described in the CY 2021 Medicare Physician Fee Schedule final rule.”

CMS emphasizes repeatedly in the CY 2024 MPFS final rule that primary care is a focal point of recent policymaking, and the implementation of add-on code +G2211 “will better recognize the resource costs associated with evaluation and management visits for primary care and longitudinal care.”

Avoid Reporting +G2211 with Modifier 25

CMS also said in the final rule that coders should not report this code in addition to an office/outpatient evaluation and management code that has 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) appended to it.

CMS gave some examples in the final rule and clarification where +G2211 should not be separately reported “when the care furnished during the office/outpatient E/M visit is provided by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature, such as but not limited to:

• for treatment of a simple virus;
• initial onset gastroesophageal reflux disease [GERD]
• and where comorbidities are either not present or not addressed and/or when the billing practitioner has not taken responsibility for ongoing medical care for that particular patient with consistency and continuity over time, or does not plan to take responsibility for subsequent, ongoing medical care for that particular patient with consistency and continuity over time.”

Note: this is not the complete list.

For further study: Find more detailed information about using +G2211 by going to www.cms.gov/files/document/physician-fee-schedule-pfs-payment-officeoutpatient-evaluation-and-management-em-visits-fact-sheet.pdf. Or, see the full ruling here https://public-inspection.federalregister.gov/2023-24184.pdf.