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.
CMS officials shed some light on G2211 during a Jan. 24 open-door forum. If the practitioner—such as the primary care physician—is the focal point for all needed services, then G2211 “could be billed,” said CMS’s Erick Carrera, according to a transcript.[3] “Or if the practitioner is part of ongoing care for a single, serious condition or complex condition such as sickle cell disease, then the add-on code could be billed. The add-on captures the inherent complexity of the visit that is derived from the longitudinal nature of the practitioner and patient relationship.”
But it’s hard to get your head around those words when CMS allows the first office/outpatient visit to be billed with G2211, Ross noted. As a vice president from an academic medical center said, “I am still struggling to understand how we can demonstrate continuing, ongoing or longitudinal care when the service is reported with a new patient visit code—99202-99205—because that relationship has not yet been established.” In response, Gift Tee, director of CMS’s Division of Practitioner Services, said CMS has been hearing that question from a lot of practitioners. Tee encouraged them to think of it as the “intention to establish a relationship given what’s being treated. We’re really looking for the idea of, you know, a primary care intervention that would require some time given a diagnosis, given the treatment guidelines and so on and so forth.” All the information would have to be in the patient’s medical records, Tee noted. “That would give us room to think about what has been billed and whether it’s appropriate, but that’s how I would broadly think about using it in that context in the new patient versus the established patient.”
There’s no cap on the number of times G2211 can be billed with an office or outpatient visit, although Tee emphasized that CMS has “a very strong program integrity framework.” The visit must be documented in a way that suggests the practitioner believes they’re “treating the patient on this longstanding, longitudinal trajectory.” Otherwise, there are no limits, Tee said—“at least not yet.”
The reminder that Medicare auditors will be looking over the shoulder of practitioners reinforces the uneasiness surrounding G2211, Ross said. “Why this patient and not that patient? That’s the black hole.”
Does Urgent Care Count as First Visit?
CMS has been definitive about aspects of G2211 in the primary care space, Ross said. When patients see another physician or non-physician practitioner (NPP) in the same practice and the same specialty as their usual physician, the stand-in physician/NPP is permitted to bill the E/M visit with the complexity add-on code. CMS also allows the use of G2211 when NPPs are providing services incident to the physician’s services.
“The longitudinal relationship is not transferable except for a substituted physician or incident-to services,” Ross said. “That’s effectively what CMS said in the open-door forum, although it’s not that clear in the final rule.”
There’s still an unknown with respect to urgent care centers. Some primary care practices open urgent care centers next door and staff them mainly with NPPs, Ross said. “It’s a way to build up a patient base,” she explained. Often, the patient’s first encounter is with the urgent care center, “but the goal is to establish a long-term patient relationship with the primary care physician.” If the first encounter is at the urgent care center, would that qualify as a longitudinal relationship? Ross said there’s no answer yet.
Most of the compliance ambiguities are with specialist billing for G2211, she said. For example, can cardiologists put the complexity add-on code on their claims for patients who they see once a year? “CMS has some work to do in the specialist space to make this a more objective test,” Ross said.
CMS also released guidance on G2211 in a Jan. 18 Medicare transmittal that included examples of its use and reiterated that G2211 isn’t allowed when E/M visits are billed with modifier 25.[4]
Here’s one of the two examples: “a patient with HIV has an office visit with their infectious disease physician, who is part of ongoing care. The patient with HIV admits to the infectious disease physician that there have been several missed doses of HIV medication in the last month. The infectious disease physician has to weigh their response during the visit —the intonation in their voice, the choice of words—to not only communicate clearly that it is important to not miss doses of HIV medication, but also to create a sense of safety for the patient in sharing information like this in the future. If the interaction goes poorly, it could erode the sense of trust built up over time, and the patient may be less likely to share their medication adherence shortcomings in the future. If the patient isn’t forthright about their medication adherence, it may lead to the infectious disease physician switching HIV medicines to another with greater side effects, even when there was no issue with the original medication. It is because the infectious disease physician is part of ongoing care, and has to weigh these types of factors, that the E/M visit becomes inherently more complex and the practitioner bills this code (G2211). Even though the infectious disease doctor may not be the focal point for all services, such as in the previous example, HIV is a single, serious condition, and/or a complex condition, and so as long as the relationship between the infectious disease physician and patient is ongoing, this E/M visit could be billed with the add-on.”
Contact Ross at mross@pyapc.com.