When and how to bill G2211: A Quick Guide

CMS Code Descriptor

Healthcare Common Procedure Coding System (HCPCS) code 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)).

Who can bill G2211

• All medical professionals who can bill Office and Outpatient(O/O) Evaluation and Management (E/M) visits (CPT codes 99202–99205 and 99211–99215).
• G2211 is not restricted to medical professionals based on their specialties.

When can we report HCPCS code G2211?

• It can be billed with a new or established (E/M) service; the only factor for consideration is that a longitudinal relationship exists or being established between the doctor and the patient.
• The practitioner provides continuous and active care for a single, serious condition or a complex condition that demands specialized clinical knowledge and ongoing management.
• Team-based care may also use G2211 if they serve as the central point of care coordination for the patient or provide ongoing specialized care.
• Telehealth services and audio calls.

✅ Use G2211 — When visit reflects complexity of longitudinal care Clinical Examples

Example 1: Chronic condition management

• Scenario: A 67-year-old with diabetes and hypertension presents for follow-up.
• Service provided: The physician reviews labs, adjusts insulin, and discusses home BP monitoring.
• Why G2211 applies: The visit reflects ongoing, longitudinal care for multiple serious conditions requiring continuous attention and coordination.

Example 2: Mental health & medical comorbidity

• Scenario: A patient with depression and heart disease visits for fatigue.
• Service provided: Evaluation addresses medication adherence, coordinates with a psychiatrist, and considers cardiac implications of treatment.
• Why G2211 applies: There's clear relationship-based and complexity-driven care beyond routine symptom management

Example 3: Care continuity over timey

• Scenario: A primary care physician (PCP) sees an established patient with COPD, monitoring pulmonary function and coordinating with pulmonology.
• Why G2211 applies: The PCP is managing a serious condition over time as part of a continuous care relationship.

❌ Do NOT use G2211 — When visit is Acute, discrete, and time-limited.

• Independently without reporting an office and outpatient E/M code on the same day of service.
• Emergency, Nursing facility & inpatient setup.

Example 1: Acute, self-limited illness

• Scenario: A healthy 28-year-old comes in for sore throat and fever.
• Service provided: Diagnosed with viral pharyngitis, given supportive care advice.
• Why G2211 does not apply: This is an episodic visit for a self-limited condition, with no ongoing relationship or chronic care

Example 2: Specialist one-time consultation

• Scenario: A dermatologist sees a new patient for a rash, provides treatment, and refers back to PCP.
• Why G2211 does not apply: There’s no established or continuous relationship, and no expectation of ongoing care from this provider.

Example 3: Pre-op clearance

• Scenario: A patient is referred for a one-time evaluation before elective knee surgery.
• Why G2211 does not apply: The service is limited in scope and duration, not part of a longitudinal management.

Key Criteria to Use G2211:

• Provider is the longitudinal care provider (usually PCP or managing specialist).
• Patient has a serious or complex chronic condition.
• Visit reflects ongoing care relationship, not one-off issue.

How to bill G2211

• No additional medical record documentation is needed.
• However, documenting and illustrating the need of E/M visit.
• The practitioner’s assessment and plan for the visit, including the time spent.
• Other service codes billed should be mentioned and serve as supporting documents for the add-on code.

Let Shoreline Medical Billing take the stress out of your Medicare billing challenges! Our expert team specializes in navigating complex Medicare regulations, ensuring accurate and compliant billing for codes like G2211 and beyond. With our tailored solutions, we streamline your claims process, reduce denials, and maximize reimbursements, so you can focus on delivering exceptional patient care.

Changes Effective

• Starting January 1, 2025 G2211 is payable with modifier 25 base code when reported by the same practitioner on the same day as an annual wellness visit (AWV), vaccine administration, or any Medicare Part B preventive service furnished in the office or outpatient setting.
• G2211 can now be added to Annual Wellness Visits (G0438 and G0439). by ensuring the AWV is on the same date and by using an appropriate E/M code with modifier 25, and documenting the longitudinal care relationship between the provider and the patient.
• Patient cost sharing, the usual Part B patient coinsurance and deductible, apply when HCPCS code G2211 is billed.
• HCPCS code G2211 may be billed during the same service period as care management services like Chronic Care Management (CCM), Transitional Care Management (TCM), or the new Advanced Primary Care Management (APCM), as long as each service meets its respective criteria and documentation guidelines.

Billing with G2211 can be beneficial for both providers and patients when done correctly. The key lies in understanding when to apply it and ensuring that your documentation supports your decision.

Trust Shoreline Medical Billing for reliable, efficient, and professional support to keep your practice thriving. Happy billing!