G2211 – Longitudinal Care Code

What Does it Mean and When Can it Be Used?

Code G2211 was released as part of the 2021 Medicare Physician Fee Schedule (PFS) Final Rule, which consolidated several thoughts the Centers for Medicare and Medicaid Services (CMS) had to code for complex visits inherently associated with primary care and non-procedural specialty care. The descriptor for this add-on code reads, “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 and or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition.”  After the 2021 PFS Final Rule was released, the Consolidated Appropriations Act (CAA) of 2021 imposed a moratorium on Medicare payment for this service. It prohibited CMS from making payment for the G2211 code before January 1, 2024.  The code was assigned a bundled payment status.

In creating the code, CMS did not believe that the time, intensity, and practice expense (PE) involved in furnishing ongoing services to patients that was accessible, coordinated with other practitioners and providers and integrated with the broader health care landscape were adequately described in the 2021 revised office and other outpatient evaluation and management (O\O E\M) visit code set. The 2021 PFS Final Rule descriptors of the service encompassed by G2211 included:

• Services that result in a comprehensive, longitudinal and continuous relationship with the patient that involved the delivery of team-based care that was accessible, coordinated with other practitioners and providers, and integrated with the broader health care landscape.
• Resources involved when practitioners furnish services that are best suited to patient’s ongoing care needs and evolving illness.
• Services that enable them to build longitudinal relationships with all patients (that is, not only those patients who have a chronic condition or single-high risk disease) and to address the majority of patients' health care needs with consistency and continuity over longer periods of time.

This 2021 PFS Final Rule provided the following two examples:

• Primary Care: “HCPCS add-on code G2211 could recognize the resources inherent in holistic, patient-centered care that integrates the treatment of illness or injury, management of acute and chronic health conditions, and coordination of specialty care in a collaborative relationship with the clinical care team.”
• Specialty Care: “HCPCS add-on code G2211 could recognize the resources inherent in engaging the patient in a continuous and active collaborative plan of care related to an identified health condition the management of which requires the direction of a clinician 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.”

These descriptors, terminology and examples are provided to help you understand the original language released with the creation of the G2211 code. The 2024 PFS Final Rule indicated that those that were uncertain as to when to report the G2211 code, should look to the 2021 PFS final rule for clarification.  

In the 2024 PFS Final Rule, CMS did not restrict billing of this add on code to higher level O\O E\M services. CMS believed the value associated with a typical visit did not account for the additional resources identified with the G2211 code regardless of the visit level. It further stated that use of the add on code was based on the relationship between the patient and the provider and was not based on the “characteristics of particular patients”. It also indicated that if an associated O/O E/M service is reported with a modifier 25, the G2211 code on that date would not be payable.

The 2024 PFS Final Rule provided that it would not be appropriate to use the G2211 code when a provider’s relationship is:

Discrete, routine or time-limited nature; such as but not limited to, a mole removal or referral to a physician for removal of a mole; for treatment of a simple virus; for counseling related to seasonal allergies, initial onset gastroesophageal reflux disease; treatment for a fracture; and 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.

CMS did not give specific documentation guidelines in the 2024 PFS Final Rule. A MedLearn Matters article released on January 18, 2024, (MM13473) had a section titled “documentation guidelines. This article indicated that the medically necessary visit needs to be documented. It stated that “we haven’t required additional documentation. Our medical reviewers may use the medical record documentation to confirm the medically necessity of the visit and accuracy of the documentation of the time you spent.” It further stated, “These items could serve as supporting documentation for billing code G2211:  information included in the medical record or in the claims history for a patient/practitioner combination such as diagnoses; the practitioner’s assessment and plan for the visit; other service codes billed.” The article also provides some good examples that will help providers as they struggle with proper use of this code and its documentation.

A definition of “longitudinal” found online states “involving information about an individual or group gathered over a period of time.” I think this definition, applied to the care of a patient, related to a single serious condition or a complex condition and their relationship with their provider and the medical care services they provide provides guidance to which patients this add on code for visit complexity should be applied. Providers who feel the care given at a visit meets the definitions given should include this code in their billing for Medicare patients.

The question of whether commercial insurances will cover and pay separately for the G2211 code remains a mystery. It is not mandated or required. Payment for the code from CMS is around $16.00.