Primary Care Coding Alert

Will G2211 and G2212 make your life easier or harder?

In addition to the telehealth additions and the revaluation of the office/outpatient evaluation and management (E/M) codes, the Centers for Medicare & Medicaid Services’ (CMS’) 2021 Physician Fee Schedule (PFS) also introduced two new HCPCS codes that you can use when you bill Medicare for prolonged or complex E/M visits.

But these two codes — 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)) and G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services) …) — may mean good and bad news for your coding this year.

Here’s how they break down.

G2211 Pros …

On the surface, the code “is good news for primary care practices, which will be able to use this code with most of the office visit E/M services they bill to Medicare,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Indeed, CMS states that even though “practitioners that rely on office/outpatient E/M visits to report the majority of their services are not likely to report HCPCS add-on code G2211 with every office visit … we are assuming that utilization will be 90 percent of office/outpatient E/M visits.”

… and Cons

However, exactly when the code should be used remains vague. “In the context of primary care, HCPCS add-on code G2211 could recognize the resources inherent in holistic, patient-centered care that integrates the treatment of illness or injury, management of acute and chronic health conditions, and coordination of specialty care in a collaborative relationship with the clinical care team,” CMS writes.

The final rule goes on to elaborate that it could be used for “active monitoring outside of office/outpatient E/M visits and are not captured in current coding,” including “oversight of medication refills; evaluating appropriateness of current and new medications, including those initially prescribed by other practitioners …; conducting medication-related monitoring and safety activities when these activities are not part of a visit …: and review[ing] of lab and imaging reports, including those requested by another practitioner, that fall outside the timeframe of an office/outpatient E/M visit, and do not necessitate a new visit.”

This suggests that G2211 will most often be used with higher-level office/outpatient E/M visits, as the clinical vignette CMS uses as an example for the code in the final rule illustrates. The example describes an encounter with an older woman with multiple complex, chronic conditions where “the clinician adjusts the dosage of some of the patient’s medications … [and] orders laboratory tests …. In this clinical example, the practitioner is serving as a focal point for the patient’s care … by furnishing care for some or all of the patient’s conditions across a spectrum of diagnoses and organ systems with consistency and continuity over time.”

G2212 Pros …

CMS’ intent in introducing this code is to resolve their disagreement with CPT^® over when service times for 99205 (Office or other outpatient visit for the evaluation and management of a new patient … 60-74 minutes of total time is spent on the date of the encounter) or 99215 (Office or other outpatient visit for the evaluation and management of an established patient … 40-54 minutes of total time is spent on the date of the encounter) enter prolonged territory.

CPT^®’s instructions for +99417 (Prolonged office or other outpatient evaluation and management service(s) beyond the minimum required time of the primary procedure which has been selected using total time, requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service, each 15 minutes of total time (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services) tell you to add the code onto 99205 or 99215 when these codes hit one minute beyond the maximum in their time ranges — 75 minutes for the new patient visit and 55 for the established.

In the 2021 proposed rule, however, CMS was proposing you add the code when the time for visits hits 15 minutes beyond the maximum time range for 99205 (i.e., 89 minutes) and 99215 (i.e., 69 minutes).

In the final rule, CMS has finalized this proposal but avoided potential confusion with CPT^® guidelines by abandoning +99417 and replacing it with G2212.

… and Cons

CMS’ adoption of G2212 is unfortunate, however, as “it means primary care practices will have to bill Medicare differently for prolonged office visits than they do payers who follow CPT^®. That means more administrative complexity, which is the last thing primary care practices need these days,” Moore notes.