BACKGROUND: 

The typical primary care physician caring for Medicare patients must coordinate care with 229 other physicians working in 117 practices. The current billing model does not account for the additional time and effort that goes into this. The Centers for Medicare & Medicaid Services (CMS) created code G2211 to account for the resource costs associated with visit complexity inherent to primary care and other longitudinal care. The code went live January 1^st, 2024. As March 2024, the national Medicare allowable for G2211 is $16.05 and three national payers have confirmed coverage: Cigna (Medicare Advantage only), Humana (commercial and Medicare Advantage), United Healthcare (commercial and Medicare Advantage). This code is in addition to E/M service codes (CPT codes 99202-99215) billed for visits and has a total RVU of 0.49, including a work component of 0.33 RVUs.  

DEFINITION: 

• “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.” 

When To Code G2211: 

• The relationship between the patient and the physician is the determining factor of when the add-on code should be billed e.g. You are the continuing focal point for all needed services 
• If you are giving ongoing care for a single, serious condition or a complex condition like sickle cell disease or HIV 
• G2211 only applies to office and outpatient E/M services  
• Cannot be used in combination with modifier 25 
• Examples when NOT to use G2211: 
  • Non-office E/M visits 
  •  Urgent care center visits (i.e., one-off visits) 
  • Transitional care management visits 
  • Medicare annual wellness visits 
  • Visits requiring modifier 25 (i.e., services that when reported on the same date as an office/outpatient E/M service necessitate adding modifier 25 to the E/M code). Examples: Annual wellness visit (G0438-G0439) | Injection of medication (96372) | Spirometry, inhalation treatment, or other pulmonary function services (94010-94799) | Osteopathic manipulative therapy (98925-98929)| Annual alcohol misuse screening (G0442) | Annual depression screening (G0444) | High-intensity behavioral counseling to prevent sexually transmitted infection (G0445) | Annual, face-to-face intensive behavioral therapy for cardiovascular disease (G0446) | Face-to-face behavioral counseling for obesity (G0447). 

 Documentation requirement 

• Routine documentation and service billing codes that describes the reason for the outpatient visit 

Patient Copays and Deductibles 

• G2211 is paid for via the Physician Fee Schedule, patient coinsurance and deductibles apply 

Learn More 

CMS How to Use the Office & Outpatient Evaluation and Management Visit Complexity Add-on Code G2211  

AAFP Guidance on G2211