After a several year delay, the Center for Medicare and Medicaid Services (CMS) began recognizing Healthcare Common Procedure Coding System code G2211 on January 1, 2024. G2211 is defined as, “Visit complexity inherent to evaluation and management [E/M] associated with medical care services that serve 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.”¹ This is an add-on code to be additionally reported at the time of submitting an office or other outpatient (O/O) E/M service, such as codes 99212-99215 and 99202-99205, when reporting criteria are met. It cannot be reported alone or at times other than that of a qualifying outpatient E/M visit. On a high level, the goal of G2211 is to offset the extra time and effort by providers who are establishing or have an established long-term relationship with a patient. The goal is that this relationship results in more mental effort on the part of the provider to incorporate long-term goals even when addressing short-term issues, resulting in improved patient care and outcomes. Which begs the question: can this code be used by specialists, such as urologists? And if so, in what circumstances?

The answer is yes, this code can be used by urologists and other specialists when specific criteria are met. While the first part of the descriptor of G2211 describes the relationship a patient may have with their primary care provider (“Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services”), the descriptor also defines the code being appropriately reported by specialists who are providing “medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition.”

Medicare went further to state that the determination of reporting the add-on code G2211 is based upon the relationship between the patient and the practitioner. CMS provided an example of a patient visiting their primary care provider for an acute problem (such as sinus congestion). They stated that the reporting of code G2211 was appropriate with the E/M visit, not due to the complexity of the acute problem per se, but rather for the cognitive load of the continued responsibility of being the focal point for all needed services for the patient, and the previously unrecognized cognitive effort of weighing the factors that affect a longitudinal doctor-patient relationship with the acute condition. As for use by a specialist, such as a urologist, the G2211 also should be reported based upon the relationship and the care for a serious or complex condition in addition to the reason for the visit, as the patient is again more likely to follow the advice of a practitioner they have a relationship with, leading to potentially improved outcomes and reduced costs.

It would therefore be inappropriate to report G2211 at the time of an office or other outpatient E/M visit if the relationship between the provider and patient was of a discrete, routine, or time-limited nature, such as but not limited to:

• a mole removal or referral to a physician for a mole removal
• treatment of a simple virus
• counseling related to seasonal allergies
• initial onset gastroesophageal reflux disease
• treatment for a fracture
• where comorbidities are either not present or not addressed and/or when the billing practitioner has not taken responsibility for ongoing medical care for that particular patient with consistency and continuity over time, or does not plan to take responsibility for subsequent, ongoing medical care for that particular patient with consistency and continuity over time.

Additionally, G2211 would not be reported if the E/M visit is appended with Modifier 25, as CMS feels that the resources of the procedure performed would account for the additional load. (While there are those who would argue that G2211 as defined should still be able to be reported in addition to an E/M service appended with Modifier 25 due to the separate and identifiable nature of the visit from the procedure, CMS stood firm.) For example, in the Final Rule, CMS specifically responded to a urology example that was submitted for comment where a 0-day global procedure (such as cystoscopy) was performed on the same date of service while the urologist is managing a separate and identifiable chronic disease and questioning why G2211 would not be reportable in those situations. CMS replied:

First, we are clarifying that Modifier 25 is reported in instances where the physician or practitioner billing the O/O E/M is the same one who is billing the significant separately identifiable procedure or other service on the same day. Commenters seemed to incorrectly suggest Modifier 25 was reported with an O/O E/M visit if the patient had a visit or procedure with another physician or another practitioner on the same day as the physician or practitioner billing the O/O E/M visit. With respect to the concern that a physician or practitioner would not perform a preventive service on the same day as an O/O E/M visit merely to avoid our policy to not pay G2211 when the O/O E/M visit is reported with Modifier 25, we intend to monitor the utilization of this code and continue engagement with interested parties as this policy is implemented. With respect to the suggestion for a new set of parallel codes for the kind of care captured by inherent complexity add-on code we believe such a set of codes could increase administrative burden with minimal benefit gained and unnecessarily delay reactivation of the complexity add-on code and payment. Similarly, we believe relying on NCCI edits to single out unbundled procedures or services with which G2211 should not be billed would also increase administrative burden and delay reactivation. Finally, for future rulemaking and as discussed in the next section, we remain open to considering additional iterations in coding and valuation within the PFS [Professional Fee Schedule] that would meet the same goals regarding the appropriate valuation of these services.²

So based upon this, when is it most appropriate in urology to report G2211? It should be reported in addition to the E/M service when seeing a patient for an office or other outpatient visit for management of a serious condition or a complex condition, except in cases where Modifier 25 is appended to the E/M service. Examples may include the management of urologic cancers, incontinence, chronic or recurrent infections, neurogenic conditions, severe recurrent stone formers, etc. While not specifically addressed, based upon the primary care example, it seems reasonable to consider reporting G2211 for an E/M visit provided to a patient with an acute problem in patients who are being followed for a serious or complex chronic condition if there is a well-established relationship and the acute problem is being treated in context of the care of the chronic condition.

There is anticipation that there will be future guidance and potential changes from the CMS on this topic in the future.