Written by Nicole Benson, BA, CPC CPMA, COSC
Since the release of visit complexity code, there has been confusion on its use and when it should be reported. HCPCS code G2211 is an add-on code to outpatient evaluation and management services only, CPT code sets 99202-99205 and 99211-99215. Other outpatient services and hospital E/M services are not applicable to the visit complexity add-on code.
Visit complexity is inherent to evaluation and management associated with medical care that serves 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. CMS recently released a frequently asked questions (FAQs) document to provide clarification on use of this code. Start by thinking about the relationship between provider and/or group and the patient when deciding whether to bill HCPCS code G2211, including whether:
• You’re the continuing focal point for all needed services, like a primary care practitioner, or
• You’re providing ongoing care for a single, serious condition or a complex condition
Per CMS, there are many visits with new or established patients where the office / outpatient (O/O) E/M visit complexity add-on code would NOT be appropriately reported. For example, when the care furnished during the E/M visit is provided by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature, and where comorbidities are either not present or not addressed. It would also be inappropriately reported when the billing practitioner has not taken responsibility for ongoing medical care with consistency and continuity over time, or does not plan to take responsibility for subsequent, ongoing medical care for a particular patient with consistency and continuity over time.
CMS has not further specified the need or indication for additional medical record documentation while reporting G2211, yet medical reviewers may use this information to confirm the medical necessity of visits and the patient care relationship with the provider as appropriate. A simple recommendation to providers reporting visit complexity is to clarify in their documentation the continuing focal relationship with the patient and regarding what single, serious or complex condition. For example, “we will serve as the continuing focal point for management of the patient’s rheumatoid arthritis and associated complications.” While this is not a CMS requirement, it does clarify the nature of the patient / provider relationship and specify the visit complexity condition.
There is no specified definition for the longitudinal relationship, only that one or both bullets above are met. Per CMS, the provider should be addressing the majority of patient’s health care needs with consistency and continuity over longer periods of time. This includes furnishing services to patients on an ongoing basis that result in care that is personalized to the patient. The services result in a comprehensive, longitudinal, and continuous relationship with the patient and involve delivery of team-based care that is accessible, coordinated with other practitioners and providers, and integrated with the broader health care landscape.
No specific diagnosis is required for G2211 to be billed, yet it would be appropriate to report a health condition that is a single, serious condition and/or a complex condition for which the billing practitioner is engaging the patient in a continuous and active collaborative plan of care related to that identified health condition. The management of which requires the direction of a practitioner with specialized clinical knowledge, skill, and experience. Such collaborative care includes patient education, expectations and responsibilities, shared decision-making around therapeutic goals, and shared commitments to achieve those goals.
There are some additional limitations in reporting G2211. Rural Health Clinic (RHC)s and Federally Qualified Health Center (FQHCs) are reimbursed at an encounter-based rate with G2211 bundled into this rate and not separately payable. In addition, Medicare will deny G2211 if it is reported with an outpatient E/M service and modifier -25 on the same day. Meaning that when another service or procedure is performed with the E/M service, G2211 cannot be added and billed. The 2025 CMS draft rule is making consideration for the allowance of preventive services with an E/M and visit complexity. The referenced FAQ and MLN article on G2211 can be accessed through the following links:
https://www.cms.gov/files/document/hcpcs-g2211-faq.pdf