Revenue Cycle Insider

Question: I think the code descriptor for G2211 makes it seem like a coder can’t bill G2211 unless the diagnosis involved in an encounter is complex. Can I really only bill G2211 for complex diagnoses?

Idaho Subscriber

Answer: The code descriptor for 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)) does indeed specify “a patient’s single, serious condition or a complex condition.” The Centers for Medicare & Medicaid Services (CMS) says that there’s no specific diagnosis required to bill G2211.

CMS says G2211 is appropriate to code and bill when the provider is reporting a “health condition that is a single, serious condition and/or a complex condition for which the billing practitioner is engaging the patient in a continuous and active collaborative plan of care related to an identified health condition—the management of which requires the direction of a practitioner with specialized clinical knowledge, skill, and experience.”

In the news release announcing the creation of G2211, CMS described the code as an acknowledgement of primary care physicians often carrying “the cognitive load, responsibility, and an accountability for building the most effective, trusting relationship possible amidst evaluating and managing other health care problems during a visit. Building an effective longitudinal relationship, in and of itself, is a key aspect of providing reasonable and necessary medical care and will make the patient more likely to comply with treatment recommendations after the visit and during future visits.”

So, while the code descriptor specifies providing care for a serious or complex condition, CMS intended the code to be used for providers to establish or maintain a certain depth to their relationships with some of their sicker patients.

Also, CMS clarifies that specialty providers can also bill G2211 if, for example, an infectious disease provider sees a patient who lives with HIV. 

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC