January 10, 2025

Expanding Payment for the 'G Code' to Commercial Payers

The 2024 WSMA House of Delegates met in Spokane last year to discuss and debate over 40 resolutions impacting the practice of medicine, patient care, and state and federal health care policy. Among those adopted by the HOD was Resolution B-15 "Expanding Payment for Visit Complexity for Office/Other Outpatient Services to Commercial Payers":

RESOLVED, that the WSMA advocate for legislative, regulatory, and policy changes that will result in commercial payers recognizing and reimbursing the G2211 add-on code (New HOD Policy).

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 or other outpatient E/M services that enable them to build longitudinal relationships with patients. After a three-year delay, the Centers for Medicare and Medicaid Services implemented code G2211 on Jan. 1, 2024.

WSMA's "G code" advocacy to date

Shortly after adoption by Medicare, the WSMA urged commercial payers operating in Washington state to reimburse for the code-some have adopted and are currently reimbursing. Of our state's Medicaid program, we were recently told by the Health Care Authority that while several Medicaid managed care plans cover the code, others consider G2211, or the G code, a bundled code and do not reimburse separately. Medicaid fee-for-service does not currently cover it but the state is conducting preliminary modeling on coverage.

Spurred on by B-15, the WSMA will take additional steps this year to hasten adoption and payment of the G code, including outreach to the Health Care Authority, managed care plans, and commercial plans operating in our state, and throwing our support behind any proposals that materialize during the 2025 legislative session.

In the meantime, we urge you to review your contracts and payment policies to understand whether the carriers you contract with cover the G code and if so, the rate and requirements for billing, as they will vary by payer.

G2211 in the 2025 Medicare fee schedule

In the 2025 Medicare Physician Fee Schedule, CMS is finalizing payment starting Jan. 1, 2025, for the G code when the same practitioner reports the O/O E/M base code on the same day as an:

• Annual wellness visit (AWV)
• Vaccine administration
• Any Part B preventive service

If you are using this code, WSMA's policy department would appreciate hearing about your experiences to date, including barriers and key payers that are not currently reimbursing the code. Please email your feedback to policy@wsma.org.