By Annie Reyes & Kim Lynch

Our work at Metis is about giving you leverage. As a clinician or administrator, knowing about new payment programs and codes and how to practically apply them in your clinic is at the top of our list.

Picture a patient you are starting on a new medication. As a primary care provider, I am responsible and need time to manage multiple comorbidities, multi-specialty care, multiple medications, etc. If you are a specialist that is also taking over the primary care coordination for a patient (think: some oncology, cardiology, nephrology, etc.), you also are also responsible for and should be paid for your time spent with these more complex patients. In 2024, the Centers for Medicare and Medicaid Services (CMS) introduced the new G2211 code to help capture this ‘quarterback of the patient’s care’ responsibility, an important new code that can benefit both your practice and your patients.

Let’s break it down. 

G codes are designed to capture patient complexity and increase payment accordingly to appropriately address that complexity. In a typical Medicare population, this likely applies to 10-40% of patients, depending on panel complexity. For example, in a 1,000 Medicare patient population, this translates to roughly 100-400 patients, and if the G2211 code was appropriately billed for 200 patients over the course of a year, it could generate up to $38,000 in additional annual revenue.

Implementing the G2211 code in your clinic can be an immediate win, and represents a bridge into value- and outcome-aligned care models that are equity based – where you can do more for the patients that need you, and be paid for it. That said, remember that like every code, it is a tool – make sure you use it appropriately and with appropriate documentation. As we all know, your billing anomalies are someone else's audit opportunity.

What is the G2211 code and why is it important?

The G2211 code is designed to empower a patient’s primary clinician and support an effective care relationship by capturing the additional complexity inherent in providing care to patients with multiple chronic conditions and/or moderate to severe comorbidities. Understanding and implementing this code can help you better document the care you provide and ensure that you are paid appropriately for the extra effort involved.

The G2211 code is used to report additional complexity in evaluation and management (E/M) services in primary care settings. It is meant to be used in conjunction with other E/M codes to indicate the complexity of care provided to patients with complex health needs.

The G2211 code is important because it allows you to capture the additional time and resources required to manage patients with multiple chronic conditions and/or moderate to severe comorbidities. By using this code, you can ensure that you are reimbursed appropriately for the care you provide.

How to implement the G2211 code in your clinic:

• Understand the criteria: Familiarize yourself with the criteria for using the G2211 code, which include managing patients with multiple chronic conditions and/or moderate to severe comorbidities.

• Yes patient example: 

• Patient you are starting on new medications -- you are going to keep a close eye on them, and have the documentation in place (the necessity behind the code). 

• Complex CHF, HTN, Diabetic patient with afib 

• May only be reported in addition to office/outpatient E/M visits (99202-99215)

• No patient example: 

• Non-Medicare

• Medicare AWV or E/M with modifier 25

• Intent was to exclude G2211 from instances where minor procedures are performed on the same date as an office visit, which often occurs outside of primary care and does not reflect the visit complexity and ongoing relationship otherwise envisioned by G2211.

• Add to your fee schedule: $17-20 is our recommendation; the 2024 national Medicare allowable for G2211 is $16.05

• Document appropriately: Ensure that your documentation clearly reflects the complexity of care provided to patients eligible for the G2211 code.

• Code accurately: Use the G2211 code in conjunction with other E/M codes (CPT codes 99202-99215, but not in conjunction with modifier 25) to accurately reflect the complexity of care provided. 

FAQs:

• Who is eligible for the G2211 code?

Patients with multiple chronic conditions and/or moderate to severe comorbidities who require additional time and resources for care management.

• How does the G2211 code impact reimbursement?

The G2211 code allows you to capture additional reimbursement for the extra complexity of care provided to eligible patients. Remember to confirm payment as you begin to bill – payers often operationalize differently and troubleshooting specific payment issues may be necessary as this new code is normalized. And if you would like help from Metis with this visibility, let us know here!

• Are there specific documentation requirements for the G2211 code?

Documentation should clearly reflect the complexity of care provided, including the number and severity of chronic conditions and comorbidities managed.

• If I don't always see my patient, how do I operationalize this in my clinic?

Providers can prep in their note, such as “If X, then Y” to enable others to act in alignment with the patient’s care plan. 

Additional resources:

• CMS guidance on G2211 (released January 18, 2024)

• American Academy of Family Physicians (AAFP) resources on G2211 (accessed March 11, 2024)

• ASCO guidance: usage of and additional requirements for reporting the G2211 code (accessed March 11, 2024)

In conclusion, the G2211 code is an important tool that can help you better document and be reimbursed for the complex care you provide to your patients. By understanding and implementing this code in your practice, you can ensure that you are providing the best possible care to your patients while also optimizing your reimbursement.

At Metis Health Technologies, we help organizations manage their healthcare business on a return-on-investment (ROI) basis – quantitatively and qualitatively, clinically, financially, and operationally. We meet clinical businesses where they are, supporting their priorities and definition of balance – be it to prioritize serving an underserved population, maximize quality scores, grow their footprint, or reach another goal. 

Within and across the Quintuple Aim, Metis helps clinics tune their business to suit their goals. We specialize in accelerating adoption of aligned care and payment models, delivering improved  outcomes, enabling greater access by helping clinicians survive and thrive.