G2211 question

[hema_anan]

Per CMS guidelines, it is not appropriate to bill G2211-Visit complexity inherent to E/M, if the patient-practitioner relationship is of a discrete, routine, or time-limited nature. How would you describe a "routine" nature?
If an ENT clinician sees patient annually for chronic seasonal allergies, would this be considered as routine or does it support ongoing longitudinal relationship for the single chronic condition?
Appreciate if anyone with experience and better understanding of this code could share their knowledge. Thank you.

 

[jkyles]

Hi, a similar question came up last year during the CPT/RBRVS symposium. The example was an annual visit for stable migraine and the answer was probably not. Here's part of what I wrote about it (Berman is Earl Berman, M.D., MALPS-L, FACP, contractor medical director for CGS Administrators):

“There has to be a care plan, it has to be longitudinal, it has to be a visit that’s the focal point for an ongoing complex, serious condition,” he explained.

For a once-a-year visit for a stable condition when the practitioner doesn’t make any changes and probably doesn’t have a care plan for the encounter, “the likelihood of that specific example being a G2211 is small,” Berman said.

“CMS went to significant lengths ... to describe some things with primary care ... the diagnosis or the conditions being treated on a given day doesn’t matter because it is really about that longitudinal relationship-building as was mentioned today about building trust,” added Peter Hollmann, M.D., AMA/Specialty Society Relative Value Scale Update Committee member.

This is a confusing code because it is about the provider/patient relationship and that can be hard to pin down. This might be the first code that is based on "vibes." But one thing to look for is whether the documentation shows the provider has any awareness of what the patient does outside of those annual visits? Are they sending them reminders, suggesting new medications, things like that? If the relationship is just The patient comes in and the provider doesn't think about them until the next visit, then that's not a G2211. Also, the nature of the condition are the allergies serious or difficult to manage?

Here is a batch of FAQs from CMS https://www.cms.gov/files/document/hcpcs-g2211-faq.pdf. I also recommend checking with your MAC to see if it has provided more detailed information.

 

[NRaizman]

The G2211 code is meant to capture the work where a practitioner is the focal point of management for a single, chronic condition.
They do NOT have to manage it with other practitioners. They do NOT have to coordinate care specifically with other providers or services. Those elements are captured with care coordination codes.
A care plan does NOT have to be documented for CMS. In fact, CMS has specifically said that there are NO DOCUMENTATION REQUIREMENTS for G2211.

Yearly visits for the management for chronic rhinosinusitis, even if relatively simple, are exactly the type of care covered by G2211. Hollmann is a great guy, and has been very involved with the creation and elaboration of the E&M codes when they were revised for 2020/2021, but he is not the arbiter of anything with regards to G2211. Still, longitudinal relationship is the key here, as he says. "Routine" is meant to suggest casual or not-the-focus-of-the-visit.

 

[jkyles]

The full descriptor states in part "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."

From the CMS FAQs I linked:

Q8: What constitutes a serious or complex condition? What diagnosis must be used?

A: No specific diagnosis is required for HCPCS code G2211 to be billed. For the billing practitioner, it would be appropriate to report 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. Such collaborative care includes patient education, expectations and responsibilities, shared decision-making around therapeutic goals, and shared commitments to achieve those goals.

The FAQ also contains covers the definition of "longitudinal" and the types of documentation MACs will be looking for, but chronicity alone doesn't automatically meet the requirement.

While it is true that Hollman isn't a CMS official, Berman is a CMD and he did not think the example of an annual visit for stable migraine justified a G2211. He also agreed with Hollman's follow up statements.

 

[hema_anan]

Thank you both @jkyles and @NRaizman for this engaging discussion. I have reviewed the CMS FAQs, AAPC and other articles and some of the MAC information. They all talk about the limited explanation that CMS has to offer and nothing beyond. The more I read the more confused I am!

I'm trying to understand what defines the visit as having "routine" nature?
Per CMS, in the context of specialist billing- it has to be single and serious or complex condition. But they also talk about the longitudinal relationship.
So if a specialist sees the patient for a specific chronic condition but non-serious (ex, chronic seasonal allergies), this would not support G2211. Or would it support based on the longitudinal relationship.. ?

As a non-clinical reviewer, I'd think if an otherwise healthy patient sees specialist for f-up of their chronic condition(DM, HTN, allergies, etc.) which is assessed as stable, provider reviews/orders tests, and advises to continue Rx regimen - this would be the typical E/m.
Versus,
the same stable chronic condition management in a patient who is non-compliant with Tx plan, has unhealthy habits(food, exercise, SUD, etc) or has other comorbidities that could increase the complexity of overall patient management, then this supports g2211.

 

[NRaizman]

As a non-clinical reviewer, I would generally defer to the provider.

Seasonal allergies are -seasonal- and only generally require a few seconds to manage with standard OTC antihistamines.

Whereas, chronic rhinosinusitis is a clearly chronic problem that can progress to surgical treatment, development of polyps, anosmia, chronic infection, and is managed with a host of treatments ranging from nasal lavage to antihistamines, to mast cell degranulation inhibitors to nasal steroids to prescription immunomodulators like Dupixent, to surgical polypectomy or FESS. The work of evaluating and managing that and figuring out within a brief period of time where a patient sits on that spectrum is what is meant to be captured by G2211.

I don't care if the management of that, for an experienced ENT, takes merely a few seconds of thought, or a few minutes of encounter time. It is the complexity of the condition, the nature of the potential treatments, and the reasoning behind it that justify the G2211, and, as CMS has explicitly said, none of that needs to be documented. Which also means, to put it very bluntly, that none of that needs to be second-guessed by coders/billers/auditors.

The whole idea of creating G2211 was to capture that work of longitudinal patient relationships and the complexity of the decision making that we do every moment of every day, even if we don't document it in our EMRs or explicitly say every bit of it.