Urology Coding Alert

Gain some clarity on this useful code.

If you’re a typical urology coder, you may find that your familiarity with +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) is still unclear. That’s why we’ve sought the advice of John C. Lin, MD, principal at Sunrise Urology in Gilbert, Arizona, and host of The Thriving Urology Practice Facebook Group for more information on this code.

Read on to learn more about how and when it’s appropriate to use +G2211.

Background: “CMS [Centers for Medicare & Medicaid Services] first proposed code +G2211 in 2021 as a way to compensate physicians for the extra work required for coordination of care for complex or serious conditions. Congress mandated a delay in implementation of the code until Jan. 1, 2024,” explains Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT® Editorial Panel advisor for ASGE in Pasadena, California. “Although CMS received mixed reviews for code +G2211, for various reasons they have elected to proceed with the implementation of the code with the revisions as proposed,” he says.

Some commenters argued there was “a lack of clarity surrounding the appropriate circumstances for reporting the inherent complexity add-on code and that combined with potential implications for patient cost-sharing, health care practitioners would experience ambiguity toward billing the code, which could result in our having overestimated utilization,” the final rule says. Others urged CMS to “align utilization estimates with the actual first year utilization of care management codes for transitional care management (TCM) and chronic care management (CCM),” while some entreated the agency to apply midyear adjustments to the conversion factor (CF) if the agency found it “overestimated utilization of the code,” the 2024 MPFS final rule highlights. However, Medicare currently recognizes that there has been an underpayment of primary care services which is why they are implementing payment of +G2211.

When should you use this code?

According to Lin, reporting “this code is not based solely on the characteristics of particular patients, but rather the relationship between the patient and the practitioner. This is the determining factor as to when this code should be billed.”

In other words, this code should be used with medical care services that are part of ongoing care related to a patient’s serious or complex condition. Some examples would include patients suffering from benign prostatic hyperplasia (BPH) with obstruction, recurrent urinary tract infection (UTI); or prostate cancer, kidney cancer, or bladder cancer, where maintaining that long-term relationship with the patient will improve compliance with follow-up and care and will likely result in decreased healthcare utilization by keeping the patients healthy.

“Keep in mind that you should not use a particular diagnosis as the sole determining factor in deciding whether +G2211 is used,” says Lin.

When is it inappropriate to use +G2211?

Remember you cannot combine this with a modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) during an evaluation and management (E/M) visit.

For example, “let’s say the practitioner performs a cystoscopy on a patient and then they find a bladder tumor. It would not be appropriate to use +G2211; because at that point, the urologist would be discussing treatment options, and deciding on a treatment plan, and would begin going through the informed consent process. None of that is included in a global period for cystoscopy, so you would use modifier 25 on the E/M visit on the same day as the cystoscopy which means you can’t use +G2211,” according to Lin in his YouTube video “HCPCS +G2211 Defined and Explained: Implementation Tips for Urology and Other Medical Practices.”

Other times it wouldn’t be appropriate to use +G2211, according to Lin:

• When the care furnished is provided by the professional whose relationship with the patient is of a discreet, routine, or time-limited nature
• If a new patient has a lifelong disability, is on Medicare, and has an acute UTI
• If a patient with a disability, is on Medicare, is referred to your provider to be evaluated for a new onset epidermoid cyst

Remember: +G2211 was originally designed to be used for Medicare and Medicare replacement plans. “That said, we have seen at least a couple of private payers reimburse this code when used,” says Lin.

CMS also wants to make clear that “the add-on code cannot be billed with an office or outpatient evaluation and management visit that is itself focused on a procedure or other service instead of being focused on longitudinal care for all needed healthcare services, or a single, serious or complex condition.” Additionally:

• CMS will monitor how the code is being utilized and make refinements, if necessary.
• Due to public input, CMS revised utilization estimates and “these modifications reduce the redistributive impact to the CY 2024 conversion factor by nearly one-third from the estimated impact described in the CY 2021 Medicare Physician Fee Schedule final rule.”

CMS emphasizes repeatedly in the CY 2024 MPFS final rule that primary care is a focal point of recent policymaking, and the implementation of add-on code +G2211 “will better recognize the resource costs associated with evaluation and management visits for primary care and longitudinal care.”

For more information, you can view Lin’s YouTube channel: https://www.youtube.com/@JCLinMD.