Complexity Add-On Code G2211: What Is It and How Is It Used in Orthopaedics?

On Jan. 1, the Centers for Medicare & Medicaid Services (CMS) implemented Healthcare Common Procedure Coding System (HCPCS) code G2211. This is an office and outpatient (O/O) evaluation and management (E/M) visit complexity add-on code intended to capture time and intensity for an O/O E/M service that is associated with continuing care of a single, serious, or complex condition. The description for code G2211 is: 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 complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established).

How to use code G2211
CMS puts an emphasis on the relationship between the physician and the patient when determining whether one should report G2211. One should bill G2211 if they are the “continuing focal point for all needed services, like a primary care practitioner,” or if the physician is giving “ongoing care for a single, serious condition or a complex condition, like sickle cell disease or HIV.”

When would an orthopaedic surgeon use this add-on complexity code? An orthopaedic surgeon is typically managing ongoing care of a single, complex chronic condition such as sarcoma or limb-length deformity. Below are some additional examples where code G2211 may apply.

• Example 1: An orthopaedic surgeon manages a teenager’s idiopathic adolescent scoliosis, managing bracing, medical treatment, and evaluation for surgical treatment and progression as needed.
• Example 2: An orthopaedic surgeon manages a patient with spastic cerebral palsy, including coordination of therapy, bracing, Botox treatment, surgical releases, school accommodations, etc.
• Example 3: A patient has chronic plantar fasciitis or Achilles tendinitis, and an orthopaedic surgeon provides a main point of contact for that care, including bracing, medication, management, physical therapy, and possible interventional treatment.
• Example 4: A patient presents to an orthopaedic surgeon with knee osteoarthritis. The orthopaedic surgeon manages that patient through the full course of treatment, including guiding therapy, prescribing braces or ambulatory aids, offering interventional treatment and weight loss, and eventually performing surgical treatment.

Code G2211 can be billed in conjunction with Current Procedural Terminology (CPT) codes 99202 to 99205 and 99211 to 99215 and is not restricted to a specific specialty. However, the intent of the add-on complexity code is to better account for additional resources associated with ongoing disease management by primary care, which CMS has stated in the calendar year (CY) 2024 Physician Fee Schedule final rule. AAOS does not anticipate that orthopaedic surgeons will be high utilizers of this code. Also note that G2211 cannot be reported when an O/O E/M code is appended with a modifier 25, for example an injection, which would qualify as a significant, separately identifiable E/M service by the same physician or other qualified healthcare professional on the same day of the procedure or other service. Medicare administrative contractors have implemented edits to deny payment of G2211 when reported with an associated O/O E/M with modifier 25.

How to document code G2211
As always, documentation is important. According to the article “How to Use the Office and Outpatient (O/O) Evaluation and Management Visit Complexity Add-on Code G2211,” from the MLN Matters: “You must document the reason for billing the O/O E/M visit. 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. Our medical reviewers may use the medical record documentation to confirm the medical necessity of the visit and accuracy of the documentation of the time you spent. 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 2024 Medicare allowable for G2211 is $16.04, and the work relative value units are 0.33. It remains to be seen whether private payers will reimburse the code. Policies will vary, and members are encouraged to review their contracts if they believe that the code will be utilized in their practices.

It should be noted that AAOS continues to oppose implementation of G2211 with use of existing E/M visits and voiced concerns to CMS in their comments to the CY 2024 Final Rule. AAOS believes that implementation of the code could result in overpayments as well as penalize all physicians due to the reduction in the Medicare conversion factor, which is required to maintain budget neutrality under the Physician Fee Schedule. AAOS also believes that the code is unnecessary due to the new O/O E/M coding structure, which allows flexibility to report a higher-level E/M code to account for increased medical decision making or total time for the patient encounter.

This article has been reviewed and edited by the AAOS Coding, Coverage, & Reimbursement Committee.

Joanne Willer, CPC, is the manager of coding and reimbursement resources in the AAOS Office of Government Relations.