G2211 Medicare Add-On Code for Primary Care
by Christina Onolaja, MHA HRMC
In 2024, The Center for Medicare and Medicaid Services (CMS) implemented a supplemental code, G2211, for primary care providers to add-on to existing Evaluation and Management services. The idea is to give PCPs a financial boost for the ongoing care and relationship with their patients. According to CMS, “G2211 captures the inherent complexity of the visit that’s derived from the longitudinal nature of the practitioner and patient relationship.”
Longitudinal relationship - two words you have heard a lot on the BoPC Podcast, Season 2.
As a healthcare leader, it is important to not only stay up to date on new or changing laws and payor programs, but to also determine the impact to the practice. This includes financial planning to ensure the practice can prosper beyond the changes. As the Administrator of a relatively small primary care practice consisting of 5 physicians and 2 physician assistants with a split model of traditional primary care and concierge medicine, our practice is greatly impacted by coding and reimbursement changes. Due to the concierge element of the practice, volumes are significantly lower than in a traditional primary care setting, so it is important to capitalize on anything that will capture additional revenue.
When the code was initially announced, there was very little guidance on how to use it. In our practice, we decided to put it on all Medicare, Medicare Advantage, and Commercial claims to see what kind of response we would receive. The Medicare allowable for the code is $16.05. We were surprised to find carriers other than Medicare were paying for this code. The reimbursement rate varied by payor and was lower for Physician Assistants with a reimbursement between $10.71 and $19.47.
G2211 can be added to many primary care claims with a few exceptions including when a 25 modifier is used or if the visit is acute or time-limited such as in a walk-in or urgent care scenario. The 25 modifier can be challenging if it is used when vaccines are administered or there are frequent procedures performed. A greater concern is when a patient is seen for a well visit and they use the dreaded “oh by the way” statement to convey an acute issue. In these cases, a 25 modifier is used as well and would not qualify for billing G2211.
The most important aspect of billing G2211, is showing the ongoing relationship between the provider and patient. It is imperative the documentation states continuous care for the patient which could be as simple as stating a return to office for follow-up. In the event of an audit, the patient history should show multiple appointments for care over a period of time with documentation regarding condition and medication management.
While the code does not completely offset the reduced Medicare reimbursement rates, it helps fill the gap. G2211 is a new code and rules are destined to evolve over time, hopefully providing even more clarity to practices. For the time being, practices should monitor CMS for updates and track payments and denials to determine if it was billed correctly.
