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G2211 is a Legislative Win: Here’s What’s Next for Primary Care

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Sometimes a billing code is so much more, and now that includes G2211. 

If you missed our blog post from a few months ago, Medicare code G2211 is now reimbursable as an add-on payment that recognizes the inherent costs clinicians often incur when longitudinally managing a patient's single, serious, or complex chronic condition. This new code, previously delayed in its implementation, ensures that primary care physicians are adequately compensated for the time, effort, and resources they invest in providing longitudinal care for their patients. 

Despite significant opposition to the implementation of G2211, it is now payable starting January 1, 2024. I believe that the addition of this code indicates a shifting policy perspective on the value that primary care provides. No other form of healthcare improves health the way primary care does, and being adequately compensated for our work is a critical milestone in recognizing primary care for the value we deliver as a profession. While policy is just one lever, it’s an important one. And, one that also needs to be shored up by more comprehensive efforts, including support from EHRs like mine.

What to know about G2211

HCPCS code G2211 is now payable under Medicare, and practices should use this new add-on code alongside office/outpatient evaluation and management (E/M) codes to receive additional payment ($16.04 per encounter) for providing high-value, longitudinal care. CMS has also added code G2211 to the approved telehealth service list (including audio-only), allowing for the addition of the code for both E/M visits performed with synchronous audio and visual and the time-based audio-only codes 99441, 99442, and 99443. 

The criteria for billing G2211 are typically met in a usual primary care visit, since it applies to any longitudinal care. According to CMS, the longitudinal nature of the relationship between the practice and the patient determines eligibility to use the code. This also means that in a multi-practitioner practice, the code can still be billed even if it’s temporarily in the absence of the patient’s usual physician.

While subspecialty practices are eligible to use G2211 for patients being followed for a single serious or complex condition, the code is uniquely suited for the work of primary care. Currently, only Medicare has promised to recognize the use of this code, but commercial plans, Medicare Advantage, and Medicaid plans may adopt use of the code at their discretion.

There are few exceptions for use of G2211. When E/M services are being provided for patients who are seen only episodically – for example, in an urgent care clinic – G2211 may not be billed. Another important exception to note is that G2211 may not be billed alongside modifier 25. Federally Qualified Health Clinics and Rural Health Clinics will not need to bill G2211, as it will be bundled into their unique payment methodologies.

How EHRs can make it easier to use G2211

The good news is that code G2211 requires no additional documentation beyond the usual E/M encounter note to justify payment. However, since the new code applies to all comprehensive, longitudinal primary care practices accepting Medicare, making it a streamlined part of the billing process is critical. EHR automation to ensure the code is accurately billed for all eligible patients and encounters will maximize practice reimbursement under this new code, potentially resulting in a significant boost to overall revenue.

While more legislation is necessary to continue bolstering primary care, G2211 represents a key step forward. We were proud to join the broad coalition of primary care champions advocating for the implementation of G2211 without further delay, and we’re committed to our tireless promotion of the primary care agenda wherever we see opportunities.

For more information about code G2211, visit the CMS Medical Learning Network Bulletin or the American Academy of Family Physicians

Sara J. Pastoor, MD, MHA is Elation's Senior Director of Primary Care Advancement and leader in primary care advocacy. Dr. Pastoor is a board certified and clinically active family medicine physician. Her experience as a primary care innovator spans a career in military medicine, academic medicine, private practice, and employer-sponsored delivery models. She received her MD from Rosalind Franklin University of Health Sciences and MHA from Trinity University.