Wiki G2211, Dermatology

[SUN1633]

Hello,
Has anyone in dermatology billed G2211 and have an example of documentation to support it? After reading the info from CMS, we are still uncertain what additional documentation may be needed in order to properly report this. Our providers believe most chronic conditions apply, such as psoriasis, atopic dermatitis. Any input is appreciated. Thank you.

 

[admin@k2derm.com]

Hello,
We have similar questions forming around G2211. I've seen a recent conversation here that suggests avoiding counseling/wellness codes -- best to use problem diagnosis code.

I've just found this on documentation:

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What needs to be documented​

According to the guidance in the Medicare Learning Network Matters: How to Use the Office and Outpatient (O/O) Evaluation and Management Visit Complexity Add-on Code G2211:

“You must document the reason for billing the O/O E/M visit. The visits themselves would need to be medically reasonable and necessary for the practitioner to report G2211. In addition, the documentation would need to illustrate medical necessity of the O/O E/M visit. We [CMS] haven’t required additional documentation. Our [CMS] medical reviewers may use the medical record documentation to confirm the medical necessity of the visit and accuracy of the documentation of the time you spent. These items could serve as supporting documentation for billing code G2211:

• Information included in the medical record or in the claims history for a patient/practitioner combination, such as diagnoses
• The practitioner’s assessment and plan for the visit
• Other service codes billed.”