CMS To Reimburse G2211 in 2024
By: Michelle Lewis, HMS Valuation Partners | Legal Research Associate
The CPT add-on code G2211, also known as the “Complexity Add-On Code,” was introduced to capture the additional resources required when primary care and certain specialty physicians provide evaluation and management (E/M) services. This code is specifically designed to account for the increased complexity in decision-making and patient care that is not otherwise captured by standard E/M codes. G2211 will specifically be used with office and other outpatient services – CPT codes 99202–99215. CMS originally proposed the G2211 code for implementation in the 2021 Medicare Physician Fee Schedule, but opposition convinced Congress to delay it until 2024. Here are few takeaways:
1. Ability to capture reimbursement for increased “complexity” of care.
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- CMS is instituting an add-on CPT code to reflect the additional work associated with care coordination for certain evaluation and management visits (E/M) that will primarily be used by primary care.
- This code can be added for a visit to ensure that practitioners are getting accurate payment for the work and the value of care they’re providing. Providers are seeing more and more complex patients, and this code allows for payment recognition associated with the increased complexity. The intent is to encourage physicians to have a longitudinal influence on the care of these patients by continuing to care for them over the long-term.
- This code is for practitioners who use E/M services to report most of their services.
- CMS believes that the value for office visit codes alone don’t adequately reflect the cost of caring for the complexity of certain kinds of visits. Furthermore, stating that the values don’t account “for the resource costs associated with primary care and other longitudinal care of complex patients.” p. 296, Proposed Rule.
2. Not all visits in primary care would be eligible.
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- These visits are defined as a “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.”
- Acute visits may not be part of continuous care, that defines G2211.
- Will not be reimbursed when used with modifier 25.
3. May not be reimbursed by all payors….yet
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- G2211 was first introduced back in 2021.
- It is only starting on January 1, 2024, that Medicare will start reimbursing for the add-on code under the 2024 Medicare Physician Fee Schedule Final Rule.
- Private Payors are not required to cover or pay for G2211.
4. Redistributing reimbursement based on budget neutrality
- CMS is decreasing CY 2024 conversion factor to $32.75, a decrease of $1.14 (or 3.34%) from the current conversion factor of $33.89.
- CMS is expected to monitor how the service is furnished after implementation.
- CMS has made predictions on how often G2211 will be used in 2024. Instead of assuming that G2211 will be billed with 90 percent of all office visit claims, CMS now estimates that G2211 will be billed with 38 percent of all office visit claims initially, but estimates that when fully adopted after several years, G2211 will be billed with 54 percent of all office visit claims.
