Key G2211 Definition Is in ‘Eye of the Beholder,’ Complicating Compliance; FAQs Are Coming

What CMS means by a “longitudinal relationship” between a physician and patient—which is required to bill the newly activated complexity add-on code (G2211)—apparently isn’t all that obvious. Although CMS generally explained what it takes to add G2211 in the 2024 Medicare Physician Fee Schedule (MPFS) rule, the Medicare manual and an open-door forum, it may not be that easy to apply to real-world situations.[1]

According to the MPFS rule, physicians and nonphysician practitioners are permitted to bill G2211 on top of an office or outpatient evaluation and management (E/M) service (99202-99205 and 99211-99215) if the add-on code describes “medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition.” The ongoing care must describe “a longitudinal relationship between the practitioner and the patient.”

Although CMS has been clear about G2211 in some respects—for example, it can be used with incident-to billing but not modifier 25—it’s squishy about longitudinal relationships, said Martie Ross, a principal with PYA.[2]

“It’s a compliance officer’s nightmare,” Ross said in an interview. “CMS believes it has created an objective standard, but all the permutations that providers raise clearly demonstrate it’s subjective. It’s in the eye of the beholder.” And CMS hasn’t been specific about how to document a longitudinal relationship with the patient, she noted. “If I pick up a record to audit, what should I look for in documentation requirements? We don’t know yet.” CMS has promised to spell out more in forthcoming FAQs on G2211.

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