CMS finalizes and implements evaluation and management visit complexity HCPCS add-on code G2211

By Faith C. M. McNicholas, RHIT, CPC, CPCD, PCS, CDC, Manager, Lead Coding and Reimbursement Strategist, May 1, 2024

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CMS has officially implemented the novel evaluation and management (E/M) office/outpatient (O/O) visit complexity add-on code G2211 effective Jan. 1, 2024. G2211 now has an “active” status indicator which allows it to be separately payable when appropriately reported.

The comprehensive code descriptor for HCPCS code G2211 is outlined as follows:

“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, or complex condition (add-on code, list separately in addition to office E/M visit, new or established).”

HCPCS code G2211 allows reimbursement for dermatologists who establish and manage enduring longitudinal relationships with patients and facilitates reporting the consistent and continuous management of patient’s health care needs over extended periods, spanning multiple sites throughout an episode of care. This includes furnishing services to patients that result in personalized patient care. These services result in a comprehensive, longitudinal, and continuous relationship with the patient and involve the delivery of team-based care that is accessible and coordinated with other clinicians, and integrated with the broader health care landscape.

The key determinant for whether the HCPCS add-on code G2211 is appropriate is the longitudinal nature of the relationship between the dermatologist and the patient. If the dermatologist is the continuing focal point for all needed health care services or if they are furnishing ongoing care related to a patient’s single, serious, and complex condition, HCPCS G2211 can be reported.

According to CMS, this code is not restricted to clinicians based on their specialties and can be used/reported by all clinicians, regardless of specialty, with O/O E/M visits of any level (other than those reported with modifier 25) wherein the care provider serves as the continuing focal point for all needed health care services and/or medical care services integral to ongoing care for a patient’s single, serious condition or a complex condition. CMS assumes that some specialties will furnish these types of services more than others.

However, because dermatologists rarely serve as the focal point for ALL of a patient’s medical and/or health care services, dermatologists will likely report G2211 based on ongoing care related to a patient’s single, serious, or complex condition.

HCPCS G2211 is an add-on code and must be reported in conjunction with an associated O/O E/M CPT code such as 99202-99205 or 99211-99215. It can also be reported when the E/M visit is provided via telehealth because CMS has permanently added the code to the Medicare telehealth list.

Additional limitations include CMS’s statement that separately identifiable E/M services occurring on the same day as minor procedures, such as those with zero or 10-day global procedures, do not justify additional payments for complexity. As such, CMS finalized that the O/O E/M visit complexity add-on code G2211 is not separately payable when reported with an O/O E/M visit appended with modifier 25.

Documentation requirements

Documentation to support reporting HCPCS code G2211 must indicate a medically reasonable and necessary reason illustrating the medical necessity for the office or outpatient E/M visit. CMS has indicated that its medical reviewers may use the medical record documentation to confirm the medical necessity of the visit and the accuracy of the documentation of the time spent by the dermatologist acting as the focal point of care including the diagnosis, dermatologist assessment, and plan for the encounter.

When HCPCS code G2211 should not be reported

CMS has provided the following instances where the O/O E/M visit complexity add-on code should not be reported, including:

• Care is provided by a clinician with a discrete, routine, or time-limited relationship with the patient.

• Procedures like mole removal, treatment of a simple virus, counseling for seasonal allergies, or initial onset of certain conditions.

• Cases where comorbidities are not present or not addressed.

• When the billing clinician has not assumed responsibility for ongoing medical care with consistency and continuity over time.

Examples of proper use of HCPCS code G2211

Example 1

A 76-year-old male established patient with cicatricial pemphigoid is seen in the office. Physical examination revealed widespread tense bullae in the trunk, abdomen, and limbs as well as conjunctival erythema and gingival erosions. High-dose prednisone therapy is initiated and steroid-sparing approaches, both with oral medications and/or IVIG, are discussed.

The dermatologist discusses this autoimmune disorder and its potential complications such as esophageal strictures and blindness as a result of scarring of the mucous membranes. The discussion includes advising the patient that management will include close follow-up with the dermatologist as well as coordination with other specialists for ongoing patient management and prevention of complications.

The determination on whether the HCPCS add-on code G2211 is reportable is based on the relationship between the dermatologist and the patient around the ongoing care for a single, serious condition or a complex condition (e.g., cicatricial pemphigoid with potential complications for which the dermatologist has to weigh in). The add-on code captures the inherent complexity of the visit that is derived from the longitudinal nature of the dermatologist and patient relationship.

Example 2

A 45-year-old male established patient presents with severe hidradenitis suppurativa for follow-up care. The patient is morbidly obese and a smoker. The dermatologist performs a thorough examination and discusses patient signs and symptoms, skin appearance, and medical history as well as management options that include medication (e.g., antibiotics, steroid injections, biologics, and/or pain medication), surgery, or both to help control symptoms and prevent complications of the condition. A weight loss program as an integral component of effective therapy is discussed.

The dermatologist further coordinates patient care by making referrals to infusion centers for infliximab, surgery for grafting, smoking cessation specialists, diabetes management, and weight loss management where necessary.

In this example, the dermatologist has a relationship with the patient and is acting as the focal point who is involved in the ongoing care for a single, serious condition or a complex condition (e.g., hidradenitis suppurativa for which the dermatologist has to coordinate the care and management with other specialists). In addition to the E/M encounter code, and based on the complexity of the condition, HCPCS code G2211 is reported for this encounter.

Examples of inappropriate use of G2211

Example 3

An established patient with atopic dermatitis who is flaring while using topical steroids comes to your office. A review of systems is negative for other atopic sequalae such as asthma. You discuss switching to dupilumab or initiating phototherapy. After a discussion of potential medication side effects and assurances that the risk of skin cancer from properly delivered ultraviolet treatments is minimal, the patient decides on phototherapy. The patient decides to initiate treatment with phototherapy on the same day which is performed and reported with an E/M visit code with modifier 25 as well as the light therapy code 96900. In addition, a short course of oral corticosteroid is prescribed to calm the atopic dermatitis flare while phototherapy takes effect. Close follow-up throughout the course of phototherapy is also scheduled.

Although this dermatologist treating a patient with atopic dermatitis is acting as the focal point of care for this single, serious, and complex condition, reporting of G2211 is not justified in this case because of the same-day phototherapy service. According to CMS guidelines, when a separately identifiable E/M service is reported on the same day as a minor procedure, the HCPCS add-on code G2211 is not reportable with an O/O E/M visit appended with modifier 25.

Alternatively, if instead of initiating phototherapy on the day of the E/M encounter, the patient is scheduled the following week, when his schedule permits, to be treated with phototherapy, modifier 25 would not be reported for the encounter. In this circumstance, add-on HCPCS code G2211 would be appropriate because the dermatologist has initiated treatment with dupilumab or a JAK inhibitor which calls for a patient-centered care of a serious, chronic condition and continued long-term treatment and follow-up plan.

Example 4

An established patient with hidradenitis suppurativa currently on multiple systemic medications prescribed by a community dermatologist is referred to you for a second opinion. Examination reveals severe scarring with fistulas and sinus tracts. You recommend some potential changes to the patient’s medical regimen and discuss the need for surgical excision of the scarred areas and fistulas that have been unresponsive to adequate medical therapy. You prepare a consultation report and provide a referral to plastic surgery for surgical treatment options.

In this case, the dermatologist is acting as a consultative specialist. Although you are helping coordinate the care for a single, serious, and complex condition and may be involved in intermittent evaluation of the condition as a consultant, you are not acting as the focal point of care, and no longitudinal relationship is established. Therefore, HCPCS add-on code G2211 should not be reported in addition to the E/M service code.

Example 5

A new patient presents with severe acute contact dermatitis over the trunk, face, and extremities due to Rhus exposure. After significant discussion about the pathophysiology of this condition as well as treatment options, the patient is treated with oral and topical corticosteroids. Follow-up is scheduled in four days to assess the adequacy of the treatment.

Although the dermatologist is acting as the focal point of care for this patient, the acute nature and self-limited scope of the dermatitis do not require the establishment of a longitudinal relationship for effective long-term management. Treatment of acute contact dermatitis does not require the G2211 add-on code to capture the increased complexity inherent in the coordinated treatment of chronic conditions.

Skin cancer monitoring

Long-term monitoring for skin cancer recurrence and metastasis requires a longitudinal relationship between a patient and dermatologist with regular and ongoing visits for evaluation. As such, reporting HCPCS add-on code G2211 code with an E/M service code for active monitoring office visits for a patient with a history of an invasive melanoma may be appropriate.

Additional information can be accessed at CMS’s Guidance for the Implementation of the O/O E/M visit Complexity Add-on Code G2211 (CR 13473) (PDF).

Additional resources:

• CY 2024 Medicare Physician Fee Schedule Final Rule

• MM13272 Matters article - Edits to Prevent Payment of G2211 with Office/Outpatient Evaluation and Management Visit and Modifier 25

• MLN Fact Sheet: Complying with Medical Record Documentation Requirements

• MM13452 Matters article – Medicare Physician Fee Schedule Final Rule Summary: CY 2024

• Modifier 25 Fact Sheet

Visit the Academy’s Coding Resource Center for additional guidance and more coding resources.

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