April 12, 2024

Medicare Payment Update: Using the New Medicare 'G' Code

After a three-year delay, the Centers for Medicare and Medicaid Services implemented code G2211 on Jan. 1, 2024. The office/outpatient evaluation and management complexity add-on code is intended to improve payment for the time, intensity, and practice expense involved when physicians furnish office/outpatient E/M office visit services that enable them to build longitudinal relationships with patients.

The list of health plans providing payment for Medicare's new add-on "G" code continues to grow. Aetna is the latest insurer to cover G2211 for Medicare Advantage claims.

For now, the plan's policy is only accessible through a physician's Aetna portal. Previously, three other national payers, Cigna (Medicare Advantage only), Humana (commercial and Medicare Advantage), and UnitedHealthcare (commercial and Medicare Advantage), had confirmed coverage of G2211.

How to use the new add-on G code

The 2024 Medicare physician fee schedule allows physicians to list G2211 in addition to codes used in office or outpatient visits for new or established patients (i.e., 99202-99215). Physicians also can use it for telehealth visits.

CMS does not restrict G2211 to medical professionals based on specialties and recommends physicians bill the code if they are the continuing focal point for all needed services, like a primary care physician or practitioner, or are giving ongoing care for a single, serious condition or a complex condition like sickle cell disease or HIV.

Here is some advice offered when using G2211 codes:

Physicians should use G2211 when:

• They have assumed or intend to assume responsibility for the patient's ongoing medical care; and
• They intend to apply the code to office and outpatient evaluation and management (E/M) services.

Physicians should not use G2211 when:

• The associated office visit's E/M services is reported with modifier 25 appended; and
• Their visits with the patient are routine or time limited. For example, a physician who sees a patient for an acute concern should not report G2211 if they have not also assumed responsibility for the patient's ongoing medical care or do not plan to take responsibility for subsequent medical care.
• Additionally, practices are encouraged to update their electronic health record and billing systems to reflect the 2024 Medicare Physician Fee Schedule to verify G2211 is added. Practice management or billing and coding staff can help with this.

Physicians should also be aware that:

• They cannot append modifier 25 when billing for G2211;
• CMS has not defined "complex condition," meaning physicians should create an internal policy on what complex condition means to them; and
• G2211 claims should not include templates and document patient-specific details.