Questions and answers — G2211
Question: What private insurances cover G2211?
Answer: As of March 1, 2024, four national payers have confirmed coverage of G2211:
- Cigna (Medicare Advantage only),
- Humana (commercial and Medicare Advantage),
- United Healthcare (commercial and Medicare Advantage), and
- Aetna (Medicare Advantage).
Question: What needs to be documented for G2211?
Answer: CMS states, “You must document the reason for billing the office and outpatient (O/O) and evaluation and management (E/M). The visits themselves would need to be medically reasonable and necessary for the practitioner to report G2211. In addition, the documentation would need to illustrate medical necessity of the O/O E/M visit. We [CMS] haven’t required additional documentation.”
American Thoracic Society (ATS) and CHEST also recommend including a detailed assessment and plan for the visit, as well as any follow-up. The complexity of the visit should be clear in your documentation to support the medical necessity for reporting the G2211.
Question: How can a provider show that a new patient visit (99202-99205) is part of continuing care?
Answer: The treating practitioner should make sure their documentation supports their intent to provide ongoing care to the patient. Establishing such intent goes beyond a statement that the provider plans to provide ongoing care or schedule a follow-up visit. The circumstances of the visit should support the extra work involved in becoming the focal point of the patient’s care or providing ongoing care for a serious or complex condition.
Question: Dr. Red works at a primary care practice, is the focal point for a patient’s care, and has reported G2211. If Dr. Yellow, who is in the same specialty, or Mr. Green, a nurse practitioner, is covering for Dr. Red, and the patient comes in for a visit, can they report G2211 for that visit?
Answer: Yes. The same specialty/same provider rules would apply in this situation. But remember that Dr. Yellow’s or Mr. Green’s documentation for that encounter must support the code.
Question: Can a resident report G2211 under the primary care exemption?
Answer: Yes, according to CMS staff, so long as the service and the documentation meet all the requirements for the exemption and the visit complexity code. For example, the resident can only report low-level E/M codes, and the resident must be “the focal point for that person’s care.”
Question: Are there frequency limits for how often we can report G2211, either for a single patient in a given time period or by a provider or a practice?
Answer: Not at this time, but make sure your providers are following the rules for reporting the code. “There’s got to be documentation that suggests why the practitioner believes they are treating the patient on this long-standing, longitudinal trajectory, and we’ll be able to see how that interaction is happening,” senior CMS staff said. CMS staff further issued a subtle warning to providers by reminding them that CMS has a very strong integrity program. Your practice can avoid problems with thorough training, frequent chart review, and encouraging the team to ask questions until you feel that everyone is comfortable with the code.