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Add-on Code G2211 Implementation Effective Jan 1, 2024

Add-on Code G2211 Implementation Effective Jan 1, 2024

Q: What is G2211?

The CY24 Medicare Physician Fee Schedule Final Rule finalized the implementation of the E/M add-on HCPCS code G2211, which took effect on January 1, 2024. This new add-on code was created to better account for the resource costs associated with E/M visits and also longitudinal care applicable to outpatient/office E/M visits as an additional payment. This add-on code acknowledges costs associated with the practitioners’ principal role of providing needed services that are part of the ongoing, longitudinal care relationship related to a patient’s single, serious condition or complex condition. The development of this code recognizes the work that goes into building a practitioner-patient relationship that long-term helps the patient be more compliant with treatments and future visits.

Q: What are some considerations for use?

  • HCPCS add-on code G2211 can be listed separately in addition to office/outpatient E/M visits for new or established patients (i.e. codes 99202-99215).
  • Reporting is not restricted based on specialty, but certain specialties will likely furnish these types of visits more than other specialties.
  • HCPCS code G2211 is not to be used when the office/outpatient E/M visit is reported with payment modifiers such as a modifier -24, -25 or -53.

Q: What are some clinical examples for possible use of G2211 in cases that are complex or serious and require long-term, longitudinal care?:

  • Head and Neck Cancer Care
  • Pediatric Airway Disorders
  • Refractory Chronic Sinusitis Management
  • Skull Base Tumor Care
  • Facial Reconstruction
  • Voice Disorders
  • Sleep Apnea Management
  • Pediatric Congenital Anomalies
  • Cleft Lip and Palate Care
  • Chronic Salivary Gland Disorders
  • Pediatric Hearing Loss
  • Complex Adult Hearing Loss
  • Thyroid and Parathyroid Disorders
  • Refractory Dizziness and Balance Disorders
  • Ongoing Treatment of Complex Rhinitis – e.g. – immunotherapy management
  • Complex Swallowing Disorders
  • Refractory Laryngopharyngeal Reflux (LPR)
  • Refractory Epistaxis
  • Chronic Otomastoiditis
  • Chronic cranial neuropathies
  • Complex chronic voice disorders
  • Migraines

Q: When should you NOT use G2211?

  • When your relationship with the patient is of a discrete, routine, or time-limited nature. For example, when you see a patient for an acute concern and have not also assumed responsibility for the patient’s subsequent, ongoing medical care with consistency and continuity over time.
  • If the associated office visit E/M is reported with modifier 25 appended
  • With CPT code 99211

Q: What is the Medicare amount for G2211 and when does it take effect?

The 2024 national Medicare allowable for G2211 is $16.04. HCPCS code G2211 is payable starting January 1, 2024.

Q: Aside from Medicare, are any other payers adjudicating this code?

At this time, only Medicare is paying for this code.

Q: What are the documentation guidelines in place for this add-on code?

The reason for using code G2211 for the visit must be documented and the visit needs to be medically reasonable and necessary for the practitioner to report this add-on code. Therefore, the documentation needs to clearly illustrate the medical necessity of the visit.

CMS has stated that their medical reviewers may use the medical record documentation to confirm the medical necessity of the visit and accuracy of the documentation of the time spent on the visit. The following items could serve as supporting documentation for billing code G2211:

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

Q: What are the implications for practice?

The introduction of G2211 is a positive step for otolaryngology practices, offering recognition and compensation for the comprehensive care often provided to patients with complex ENT issues. It emphasizes the value of cognitive services and care coordination, aspects that are pivotal in managing chronic and serious conditions in our field.

Q: What are some next steps for your practice?

You are encouraged to review your contracts and speak with your provider relations representatives about adding G2211 to your fee schedule.  Private payers are not required to cover and pay separately for G2211; their policies will vary.

Update your EHR and/or billing systems to reflect the 2024 Medicare physician fee schedule.

Educate your administration and coding staff about the importance of G2211.

Q: Is there an example where using add-on Code G2211 is appropriate?

Example: A patient sees their otolaryngologist-head and neck surgeon to be evaluated for sinus congestion. The inherent complexity captured by HCPCS code G2211 is not in the clinical condition itself (chronic rhinosinusitis) but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.

In this example, the otolaryngologist-head and neck surgeon could recommend conservative treatment including the prescription of antibiotics. If the otolaryngologist-head and neck surgeon recommends conservative treatment and no new prescriptions, patients may think the doctor is not taking the patient’s concerns seriously and it could erode the trust placed in that practitioner. In turn, an eroded otolaryngologist-head and neck surgeon and patient relationship may make it less likely the patient would follow that practitioner’s advice on a needed treatment at the next visit. The otolaryngologist-head and neck surgeon must decide what course of action and choice of words in the visit itself, would lead to the best health outcome in this single visit, while simultaneously building up an effective, trusting longitudinal relationship with this patient for all their primary health care needs. Weighing these factors, even for a seemingly simple condition like sinus congestion, makes the entire interaction inherently complex, and it is this complexity in the relationship between the doctor and patient this code captures.

 

 

IMPORTANT DISCLAIMER NOTICE
CPT FOR ENT ARTICLES ARE A COLLABORATIVE EFFORT BETWEEN THE ACADEMY’S TEAM OF CPT ADVISORS, MEMBERS OF THE PHYSICIAN PAYMENT POLICY (3P) WORKGROUP, AND HEALTH POLICY STAFF. ARTICLES ARE DEVELOPED TO ADDRESS COMMON CODING QUESTIONS RECEIVED BY THE HEALTH POLICY TEAM, AS WELL AS TO CLARIFY CODING CHANGES AND CORRECT CODING PRINCIPLES FOR FREQUENTLY REPORTED ENT PROCEDURES. THESE ARTICLES ARE NOT INTENDED AS LEGAL, MEDICAL, OR BUSINESS ADVICE AND ARE NOT A GUARANTEE OF REIMBURSEMENT. THE INFORMATION IS ALSO NOT MEANT TO SERVE AS THE DEFINITIVE OR SOLE AUTHORITY ON BILLING AND CODING ISSUES. THE APPLICABILITY OF AAO-HNS BILLING AND CODING GUIDANCE FOR A PARTICULAR PROCEDURE, MUST BE DETERMINED BY THE RESPONSIBLE PHYSICIAN IN LIGHT OF ALL THE CIRCUMSTANCES PRESENTED BY THE INDIVIDUAL PATIENT. YOU SHOULD CONSULT WITH YOUR OWN ADVISORS AS WELL AS MEDICARE OR PRIVATE CARRIERS IN MAKING ANY DECISIONS ABOUT HOW TO BILL AND CODE PARTICULAR SERVICES OR PROCEDURES.
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