office visit cpt code medicare

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Office/Outpatient E/M Codes

2021 e/m office/outpatient visit cpt codes.

The tables below highlight the changes to the office/outpatient E/M code descriptors effective in 2021.

More details about these office/outpatient E/M changes can be found at CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.

All specific references to CPT codes and descriptions are © 2023 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.

Download the Office E/M Coding Changes Guide (PDF)

Evaluation and management (E/M) services are an essential part of medical practices, especially in family medicine. These services are categorized using Current Procedural Terminology (CPT) codes for billing purposes. Properly documenting and coding for E/M services is crucial to maximize payment and minimize audit-related stress.

There are different levels of E/M codes, determined by the medical decision-making or time involved. It’s worth noting that the guidelines for E/M coding have undergone changes, including the elimination of history and physical exam elements, revisions to the MDM table, and an expanded definition of time for E/M services.

Key Takeaways:

• Understanding E/M codes and guidelines is crucial for accurate billing.
• There are different levels of E/M codes based on medical decision-making or time involved.
• Recent changes to E/M coding include the elimination of history and physical exam elements.
• The definition of time for E/M services has been expanded.
• Proper documentation and coding help maximize payment and reduce audit-related stress.

Overview of Office Visit CPT Code Changes

The CPT Editorial Panel made significant revisions to the documentation and coding guidelines for office visit E/M services in 2021, with further changes introduced in 2023. These updates aim to simplify documentation requirements, reduce administrative burden, and ensure accurate coding for evaluation and management services.

One of the key changes introduced is the addition of add-on code G2211. This code accounts for the resource costs associated with visit complexity inherent to primary care and other longitudinal care settings. The inclusion of this add-on code reflects a more comprehensive understanding of the unique challenges and workload associated with these types of visits.

Additionally, the revisions eliminate the requirement for history and physical exam elements to be considered in E/M code level selection. This change allows healthcare providers to focus more on medical decision-making (MDM) and limits the need for extensive documentation of these elements in the medical record.

The MDM table has also been revised to better reflect the cognitive work required for evaluation and management services. This ensures that the complexity of the MDM is accurately captured in the coding process and supports appropriate reimbursement for the level of care provided.

Furthermore, the definition of time for many E/M services has been expanded. The expanded definition of time includes both face-to-face and non-face-to-face components of care on the day of the encounter. This change recognizes the comprehensive nature of care provided and allows for a more accurate reflection of the time spent in the management of the patient.

Using Total Time for Office Visit CPT Code Selection

When it comes to selecting the appropriate office visit CPT code, total time can be a valuable factor to consider. Total time refers to the sum of all the physician’s or qualified health professional’s (QHP) time spent in caring for the patient, both face-to-face and non-face-to-face, on the day of the encounter. This expanded definition of time allows for a more comprehensive evaluation and management of the patient’s needs.

Total time can be utilized in selecting the level of service for various evaluation and management services, including office visits, inpatient and observation care, consultations, nursing facility services, home and residence services, and prolonged services. It provides a broader perspective on the physician’s involvement in the patient’s care, taking into account all aspects of their interaction.

However, it’s important to note that for emergency department visits, the level of service is still determined primarily by medical decision-making (MDM), rather than total time. This distinction recognizes the critical nature of emergency care and the need for prompt assessment and action.

Accurate documentation of the total time spent is key to ensuring proper code selection and appropriate reimbursement. The total time should be well-documented in the patient’s medical record, including both the face-to-face and non-face-to-face components of the encounter. This documentation serves as a crucial reference point for billing and auditing purposes.

To summarize, total time offers a comprehensive perspective on the physician’s engagement with the patient, encompassing both face-to-face and non-face-to-face interactions. It allows for a more accurate selection of office visit CPT codes and ensures the appropriate level of reimbursement for the provided services. Proper documentation of total time is essential to support the medical necessity of the encounter and maintain compliance with coding and billing guidelines.

Documentation Requirements for Total Time Calculation

When determining the total time for selecting office visit CPT codes, it is essential to adhere to specific documentation requirements. By accurately documenting the time spent on various activities during the encounter, healthcare providers can ensure proper code selection and optimize reimbursement.

To calculate the total time for office visit code selection, the following activities should be included:

• Reviewing external notes/tests
• Performing an examination
• Counseling and educating the patient
• Documenting in the medical record

These activities reflect the time personally spent by the physician or qualified health professional (QHP) on the date of the encounter. However, there are also activities that should be excluded when calculating total time:

• Time spent on activities typically performed by ancillary staff
• Time related to separately reportable activities

It is crucial to specifically document the total time spent on each activity during the date of the encounter, rather than providing generic time ranges. This detailed documentation ensures transparency and accuracy in code selection and reimbursement.

In addition to capturing face-to-face time, it is important to record non-face-to-face time as well. Non-face-to-face time includes tasks performed outside of direct interaction with the patient, such as reviewing test results or consulting with other healthcare professionals.

Example of Total Time Calculation:

Let’s consider an example where a family physician spends the following time on a patient encounter:

• 45 minutes performing an examination and counseling
• 15 minutes reviewing external notes/tests
• 10 minutes documenting in the medical record
• 5 minutes discussing with an ancillary staff

In this case, the total time would be calculated as follows:

By accurately documenting the specific total time spent on each activity and excluding ancillary staff time, healthcare providers can ensure proper code selection and reimbursement. This meticulous documentation of total time in the medical record provides a comprehensive overview of the services rendered and supports accurate billing.

Split or Shared Visit Documentation Guidelines

A split or shared visit occurs when a physician and other qualified health professional (QHP) provide care to a patient together during a single Evaluation and Management (E/M) service. In such cases, the time personally spent by the physician and QHP on the date of the encounter should be summed to define the total time.

However, only distinct time should be counted. This means that overlapping time during jointly meeting with or discussing the patient should not be double-counted. The distinct time should represent the unique contribution of each provider involved in the split or shared visit.

It is important to note that time spent on activities performed by ancillary staff should not be included in the total time calculations. The total time should only reflect the face-to-face time and distinct time spent by the physician and other QHP directly involved in providing the medically necessary services.

Documentation should support the medical necessity of both services reported in a split or shared visit scenario. This includes clearly documenting the need for both physicians or QHPs to be involved and the services each provider contributed to the patient’s care.

Applying Total Time to Specific E/M Services

Total time is a valuable tool for selecting the appropriate level of service for a variety of Evaluation and Management (E/M) services. This method can be applied to different specific E/M services, ensuring that the level of care is clinically appropriate and adequately reimbursed. By considering the total time spent during the encounter, healthcare providers can accurately assign the appropriate office visit CPT code.

The application of total time is not limited to office visit services. It can also be used for inpatient and observation care services, hospital inpatient or discharge services, consultation services, nursing facility services, and home or residence services. This flexibility allows for a comprehensive approach to E/M coding, regardless of the specific type of service provided.

When selecting the visit level based on total time, it is important to ensure that the encounter is counseling-dominated. While total time can be used as the sole determinant for selecting the visit level, counseling should still play a significant role in the encounter. This ensures that the level of service reflects the complexity and intensity of the counseling provided during the visit.

It is crucial to emphasize that total time should be clinically appropriate and supported by documentation in the medical record. This documentation should clearly demonstrate the medical necessity of the services provided and the time spent on the date of the encounter.

Applying Total Time to E/M Services: An Example

To illustrate the application of total time to specific E/M services, let’s consider an example of an office visit for a counseling-dominated encounter:

In this example, the total time spent during the encounter determines the appropriate level of visit code. For a total time of 25 minutes, a level 3 visit (CPT code 99213) is selected. If the total time is 40 minutes, a level 4 visit (CPT code 99214) would be appropriate. Finally, a total time of 60 minutes would result in a level 5 visit (CPT code 99215).

By applying total time to specific E/M services, healthcare providers can ensure accurate coding and appropriate reimbursement for the care provided. This method promotes comprehensive and patient-centered care while maintaining compliance with coding guidelines. Understanding the nuances of applying total time is essential for optimizing billing practices and promoting quality healthcare delivery.

Caveats and Considerations for Time-based E/M Coding

When utilizing time as the basis for selecting E/M codes, there are important caveats and considerations to keep in mind. Time-based coding should only be used in situations where counseling dominates the encounter, and it should not include time spent on separately reportable services. Documentation should clearly indicate that the services provided were not duplicative and were necessary for the management of the patient. Additionally, it is crucial to note that the professional component of diagnostic tests/studies and activities performed on a separate date should not be included in the total time calculation.

Considerations for Time-based E/M Coding

• Use time-based coding only when counseling dominates the encounter.
• Exclude time spent on separately reportable services.
• Ensure documentation supports the necessity of the provided services.
• Do not include the professional component of diagnostic tests/studies.

Implications of Time-based E/M Coding

When selecting E/M codes based on time, it is important to adhere to the specified guidelines and considerations. Failing to do so can lead to inaccurate coding, reimbursement issues, and potential compliance concerns. By understanding the requirements and accurately documenting the relevant information, healthcare providers can ensure proper medical billing and maintain compliance with coding and documentation guidelines.

Documentation Requirements for Time-based E/M Coding

Updates and Changes to CPT E/M Guidelines

The CPT Editorial Panel has recently implemented updates and changes to the Evaluation and Management (E/M) guidelines, specifically focusing on medical decision making (MDM), history, and exam. These updates aim to enhance the accuracy and specificity of E/M coding and documentation.

One significant change in the new guidelines is the emphasis on a medically appropriate history or exam, rather than relying solely on the number or complexity of problems addressed. This shift highlights the importance of gathering comprehensive patient information to guide medical decision making.

The MDM levels have also been revised to align with those used for office visits. This alignment ensures consistency across different types of E/M services and facilitates accurate code selection for medical billing and reimbursement.

By updating and refining the guidelines, the CPT Editorial Panel aims to streamline the coding and documentation process, making it easier for healthcare providers to accurately capture the complexity of patient encounters and facilitate proper reimbursement.

Changes in CPT E/M Guidelines

| Old Guidelines | Updated Guidelines | |—————————-|———————————| | Emphasized number of | Emphasize medically appropriate | | problems addressed | history or exam | | MDM levels differed across | MDM levels align with office | | different E/M services | visit levels | | | |

The updates in the CPT E/M guidelines bring about significant changes in capturing the complexity of patient encounters. Healthcare providers should familiarize themselves with these updates to ensure compliance with the revised guidelines, thereby facilitating accurate coding, billing, and reimbursement.

Guidelines for MDM Selection in E/M Services

In the process of selecting the appropriate E/M codes for evaluation and management (E/M) services, medical decision making (MDM) plays a crucial role. MDM encompasses several factors that need to be considered, including the number and complexity of problems addressed, comorbidities, the amount and complexity of data reviewed and analyzed, and the risk of complications, morbidity, or mortality.

It is important to note that the final diagnosis alone does not determine the complexity of MDM. Rather, the complexity is determined by the impact of the condition on the management of the patient. The more complex the problems, comorbidities, and data analysis, as well as the higher the risk of complications, morbidity, or mortality, the more intricate the MDM.

In accurately reflecting the level of complexity in the documentation and coding of E/M services, healthcare providers ensure proper reimbursement and compliance with coding guidelines. By carefully evaluating the factors that contribute to MDM, providers can effectively demonstrate the complexity of the problems addressed and the resources required to manage them.

Here is a breakdown of the key considerations for MDM selection in E/M services:

• Number and complexity of problems addressed
• Comorbidities
• Amount and complexity of data reviewed and analyzed
• Risk of complications, morbidity, or mortality
• Final diagnosis and its impact on management
• Complexity of problems and their management

Accurately documenting and coding the appropriate level of MDM is essential for ensuring proper reimbursement and comprehensive representation of the complexity of the patient’s condition. It is crucial to pay attention to the specifics of each patient’s case and make informed decisions based on thorough evaluation and analysis.

Impact of Office Visit CPT Code Changes on Medical Billing

The changes in office visit CPT code guidelines have had a significant impact on medical billing and reimbursement. Healthcare providers must adapt to these changes and understand the documentation requirements and accurate coding necessary to ensure proper reimbursement and reduce the risk of audits.

Accurate coding is crucial in accurately reflecting the level of service provided during the office visit. It ensures that healthcare providers receive accurate reimbursement for their services and helps to reduce the burden of potential audits. Proper documentation and coding also contribute to compliance with coding and documentation requirements, mitigating the risk of financial loss and noncompliance.

It is essential for healthcare providers to familiarize themselves with the new guidelines and understand how to properly document the relevant information. This includes accurately capturing the level of service provided, the complexity of problems addressed, and the time spent on the date of the encounter. By adhering to these documentation requirements, healthcare providers can ensure accurate coding and reimbursement, reducing the risk of claims denials or audits.

Proper documentation not only helps in accurate coding and reimbursement but also simplifies auditing processes, ensuring compliance with coding and documentation requirements. Auditing plays a vital role in the healthcare system, and having the appropriate documentation in place can streamline the auditing process and provide evidence of accurate and compliant billing practices.

Compliance with coding and documentation requirements is essential to avoid potential financial loss and maintain a good standing within the healthcare industry. By accurately documenting and coding office visit services, healthcare providers can demonstrate their commitment to compliance and ensure that they are providing high-quality care to their patients.

In conclusion, the changes in office visit CPT code guidelines have had a significant impact on medical billing and reimbursement. It is crucial for healthcare providers to understand the documentation requirements, accurately code the services provided, and ensure compliance with coding and documentation guidelines. By doing so, healthcare providers can streamline the billing process, reduce the risk of audits, and ensure accurate reimbursement for their services.

Resources for Understanding Office Visit CPT Code Guidelines

When it comes to understanding the guidelines for office visit CPT codes and navigating the changes in E/M coding, healthcare providers can rely on valuable resources provided by reputable organizations such as the American Medical Association (AMA) and the Medicare Learning Network (MLN). These resources offer comprehensive guidance and tools that can help healthcare providers stay up to date and ensure accurate reimbursement.

The CPT Evaluation and Management Services Guidelines, developed by the AMA, provide detailed information on office visit CPT codes, E/M coding principles, and documentation requirements. This resource serves as a comprehensive guide to help healthcare providers understand the intricacies of office visit coding and ensure compliance with the latest guidelines.

The Medicare Learning Network, an educational resource developed by the Centers for Medicare & Medicaid Services (CMS), offers webinars, articles, and other educational materials specifically designed to assist healthcare providers in understanding and implementing the changes in E/M coding. These resources provide practical insights and clarification on the documentation requirements and coding changes specific to office visit CPT codes.

Furthermore, the Medicare Physician Fee Schedule Lookup Tool, available on the CMS website, enables healthcare providers to access reimbursement information for specific office visit CPT codes. This tool allows providers to accurately determine the appropriate reimbursement for their services and ensure proper billing practices.

By leveraging these resources, healthcare providers can enhance their understanding of office visit CPT code guidelines, navigate the complexities of E/M coding, and ensure accurate reimbursement for their services. Staying informed and utilizing these valuable resources is imperative for maintaining compliance and optimizing coding practices.

Understanding the guidelines for office visit CPT codes is essential for accurate medical billing and insurance reimbursement. The recent changes in E/M coding guidelines, particularly regarding time-based code selection and medical decision making, necessitate proper documentation and accurate coding. By comprehensively understanding these guidelines, healthcare providers can maximize their payment, reduce the stress associated with audits, and ensure compliance with coding and documentation requirements.

Accurate medical billing is crucial for healthcare practices to receive fair reimbursement from insurance companies. By following the comprehensive guide provided by the American Medical Association (AMA) and the Medicare Learning Network (MLN), healthcare providers can confidently navigate the complexities of office visit CPT codes. This comprehensive guide provides detailed information on selecting the appropriate codes based on medical decision making, time-based code selection, and documentation requirements.

Properly documenting the relevant information and coding accurately not only ensures accurate reimbursement but also reduces the risk of audits and increases compliance. By adhering to the guidelines and best practices outlined in the comprehensive guide, healthcare providers can maintain accurate and compliant medical billing practices, ultimately benefiting both their practice and their patients.

In conclusion, understanding the guidelines for office visit CPT codes is crucial for accurate medical billing and insurance reimbursement. By following the comprehensive guide provided by industry resources such as the AMA and MLN, healthcare providers can navigate the changes in E/M coding and ensure compliance with coding and documentation requirements. This comprehensive understanding of the guidelines allows healthcare providers to optimize payment, minimize audit-related stress, and maintain accurate and compliant medical billing practices.

What are office visit CPT codes?

Office visit CPT codes are evaluation and management (E/M) codes used for billing purposes in family medicine practices and other healthcare settings.

What are the changes to the office visit CPT code guidelines?

The office visit CPT code guidelines have been revised to eliminate the history and physical exam elements, introduce an add-on code for visit complexity, revise the medical decision-making table, and expand the definition of time for E/M services.

How can total time be used for office visit CPT code selection?

Total time, which includes both face-to-face and non-face-to-face interactions, can be used to select the level of service for office visit codes and other E/M services.

What should be included in the calculation of total time for office visit code selection?

Activities such as examining the patient, counseling and educating the patient, reviewing external notes/tests, and documenting in the medical record should be included in the calculation of total time. Ancillary staff time and time related to separately reportable activities should be excluded.

How should total time be documented for office visit code selection?

It is important to document the specific total time spent on activities on the date of the encounter in the patient’s medical record, rather than providing generic time ranges.

What are the documentation guidelines for split or shared visits?

In a split or shared visit scenario, the time personally spent by the physician and other qualified health professional (QHP) should be summed to define total time. Distinct time should be counted, and time spent on activities performed by ancillary staff should not be included.

Can total time be used for other E/M services besides office visits?

Yes, total time can be used to select the level of service for inpatient and observation care services, hospital inpatient or discharge services, consultation services, nursing facility services, and home or residence services.

What are the caveats and considerations for time-based E/M coding?

Time-based coding should only be used when counseling dominates the encounter, and it should not include time spent on separately reportable services. It is important to ensure that the services provided were necessary for the management of the patient.

What updates have been made to the CPT E/M guidelines?

The CPT E/M guidelines have been updated to emphasize the need for a medically appropriate history or exam and to revise the levels of medical decision making to align with office visit levels.

How is medical decision making (MDM) determined in E/M services?

MDM is determined by considering the number and complexity of problems addressed, comorbidities, the amount and complexity of data reviewed and analyzed, and the risk of complications, morbidity, or mortality.

What is the impact of the office visit CPT code changes on medical billing?

The changes in office visit CPT code guidelines have a significant impact on medical billing, requiring proper documentation and accurate coding to ensure accurate reimbursement and reduce the risk of audits.

Where can healthcare providers find resources to understand the office visit CPT code guidelines?

Healthcare providers can refer to resources such as the CPT Evaluation and Management Services Guidelines from the American Medical Association and the Medicare Learning Network for guidance on understanding and implementing the office visit CPT code guidelines.

What is the importance of understanding office visit CPT code guidelines?

Understanding office visit CPT code guidelines is crucial for accurate medical billing, insurance reimbursement, and compliance with coding and documentation requirements.

What is the overall purpose of the comprehensive guide on office visit CPT code guidelines?

The comprehensive guide on office visit CPT code guidelines provides healthcare providers with a thorough understanding of the guidelines, enabling them to maximize payment, reduce the stress associated with audits, and ensure compliance with coding and documentation requirements.

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List of CPT/HCPCS Codes

We maintain and annually update a List of Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) Codes (the Code List), which identifies all the items and services included within certain designated health services (DHS) categories or that may qualify for certain exceptions. We update the Code List to conform to the most recent publications of CPT and HCPCS codes and to account for changes in Medicare coverage and payment policies. Code List updates for years 2022 and earlier were published in the Federal Register as an addendum to the annual Physician Fee Schedule final rule. 

Beginning with the Code List effective January 1, 2023, updates are published solely on this webpage.  On or before December 2 nd of each year, we will publish the annual update to the Code List and provide a 30-day public comment period using www.regulations.gov . To be considered, comments must be received within the stated 30-day timeframe. We anticipate that most comments will be addressed by April 1 st ; however, a longer timeframe may be necessary to address complex comments or those that require coordination with external parties. If no comments are received, in lieu of a comment response, we will publish a note below the applicable Code List year stating so. 

2024 Annual Update to the Code List

Below you will find the Calendar Year (CY) 2024 Code List published November 29, 2023 and a description of the revisions for CY 2024, our response to comments on that Code List, and the updated CY 2024 Code List, which is effective January 1, 2024 unless otherwise indicated on the Code List.

• UPDATED list of codes effective January 1, 2024, published March 1, 2024 (all codes effective January 1, 2024 unless otherwise indicated on the Code List) (ZIP)
• List of codes effective January 1, 2024, published November 29, 2023 (ZIP)
• Annual Update to the List of CPT/HCPCS Codes Effective January 1, 2024 (PDF)

We received one comment related to the additions, deletions, and corrections to the codes on the Code List effective January 1, 2024. Our response to this comment is below. We also received one comment related to Medicare coverage for platelet-rich plasma treatments. We consider this comment to be outside the scope of the annual update. CMS does not respond to out of scope comments on the annual updates to the Code List. 

Comment : One commenter noted that, although most Hepatitis B vaccine codes are identified on the Code List as CPT/HCPCS codes to which the exception for preventive screening tests and vaccines at § 411.355(h) applies, the Hepatitis B vaccine associated with CPT code 90739 was not listed. The commenter requested that CPT code 90739 be added to the list of vaccine codes to which the exception for preventive screening tests and vaccines at §411.355(h) applies, effective retroactively to January 1, 2024.

Response : We agree with the commenter that the exception for preventive screening tests and vaccines at § 411.355(h) should apply to CPT code 90739 and are revising the Code List accordingly. The applicability of the exception for preventive screening tests and vaccines to CPT code 90739 is prospective only and effective on the date indicated on the UPDATED list of codes. 

In considering this comment, we also identified two CPT codes (90653 and 90658, both flu vaccines) that were inadvertently left off of the list of codes to which the exception for preventive screening tests and vaccines at § 411.355(h) should apply. Accordingly, we are adding these CPT codes to the list of codes to which the exception at § 411.355(h) applies, effective on the date indicated on the UPDATED list of codes.

2023 Annual Update to the Code List

Below you will find the Code List that is effective January 1, 2023 and a description of the revisions effective for Calendar Year 2023. 

• List of codes effective January 1, 2023, published December 1, 2022
• Annual Update to the List of CPT/HCPCS Codes Effective January 1, 2023, published December 1, 2022 (PDF)

The comment period ended December 30, 2022. We did not receive any comments related to the additions, deletions, and corrections to the codes on the Code List effective January 1, 2023. We received one (1) comment related to the supervision level required for specific services. We consider this comment to be outside the scope of the annual update. CMS does not respond to out of scope comments on the annual updates to the Code List. 

DHS Categories

The DHS categories defined by the Code List are:

• clinical laboratory services;
• physical therapy services, occupational therapy services, outpatient speech-language pathology services;
• radiology and certain other imaging services; and
• radiation therapy services and supplies.

The Code List also identifies those items and services that may qualify for either of the following two exceptions to the physician self-referral prohibitions: 

• EPO and other dialysis-related drugs (42 CFR § 411.355(g)).
• Preventive screening tests and vaccines (42 CFR § 411.355(h)).

NOTE: The following DHS categories are defined at 42 CFR §411.351 without reference to the Code List:

• durable medical equipment and supplies;
• parenteral and enteral nutrients, equipment and supplies;
• prosthetics, orthotics, and prosthetic devices and supplies;
• home health services;
• outpatient prescription drugs; and
• inpatient and outpatient hospital services.

Related Links

• List of codes effective January 1, 2022, published November 19, 2021
• List of codes effective January 1, 2021, issued December 1, 2020
• List of codes effective January 1, 2020, published December 2, 2019
• List of codes effective January 1, 2019, published November 23, 2018
• List of codes effective January 1, 2018, published November 3, 2017 [ZIP, 59KB]
• List of codes effective January 1, 2017, published November 16, 2016 [ZIP, 54KB]
• List of codes effective January 1, 2016, published October 30, 2015 [ZIP, 58KB]
• List of codes effective January 1, 2015, published November 13, 2014 (79 FR 67972) [ZIP, 54KB]
• List of codes effective January 1, 2014, published December 10, 2013 (78 FR 74791) [ZIP, 54KB]
• List of codes effective January 1, 2013, published November 16, 2012 (77 FR 69334) [ZIP, 54KB]

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A majority of family medicine visits should qualify for the visit complexity add-on code. Here's how to start using it in your practice.

THOMAS J. WEIDA, MD, FAAFP, AND JANE A. WEIDA, MD, FAAFP

Fam Pract Manag. 2024;31(2):6-10

Author disclosures: no relevant financial relationships.

Primary care is unique in that it is based on an ongoing relationship with patients. Effective Jan. 1, 2024, traditional Medicare (and some Medicare Advantage plans) will recognize the value of that relationship by reimbursing for HCPCS code G2211, which clinicians can add on to an office/outpatient visit evaluation and management (E/M) code. G2211 documents that the longitudinal relationship has complexity beyond that captured in the work of standard E/M codes. This complexity exists for chronic care and even some acute care visits. The deciding factor is the continuing relationship between the clinician and the patient.

DEFINITION OF G2211

The Centers for Medicare & Medicaid Services (CMS) defines G2211 as follows:

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 a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.) 1

There are two aspects to this definition. The first part underscores that the basis for G2211 is not the patient's clinical condition but the clinician's continued responsibility for the patient. The second part acknowledges that an ongoing relationship may exist for a single, serious condition or a complex condition even if the clinician is not the focal point for all services; CMS provides the example of a patient with HIV who receives ongoing care from an infectious disease doctor. 2

CMS created the new G2211 add-on code to recognize that the longitudinal relationship with a patient has complexity beyond that captured in the work of standard E/M codes.

Code G2211 can be added to office/outpatient E/M visits (99202-99205 or 99211-99215) based on the clinician's continued responsibility for the patient, not based on the patient's clinical condition.

Additionally, even if the clinician is not the focal point for all services for the patient, an ongoing relationship may exist for a “single, serious condition or a complex condition,” justifying use of G2211.

USING G2211

G2211 may only be added to a new or established patient office/outpatient visit E/M code (99202-99205 or 99211-99215). It may be added whether medical decision making or time is used to select the level of service. G2211 may be used for either chronic care visits (with no minimum number of chronic conditions needed to qualify) or acute visits as long as a longitudinal relationship exists or will exist with the patient. Therefore, a new patient visit can qualify when the patient will be establishing with the clinician as their medical home, and an acute care visit with an established patient can qualify if the clinician's practice serves as the continuing focal point for all needed health care services.

CMS has not required any additional documentation to support code G2211. However, if there might be any doubt about the longitudinal patient relationship (or intent to provide longitudinal care), it may be helpful to demonstrate it in the visit note. Particularly for acute problems, documenting the longitudinal relationship's impact on the acute visit could be helpful. For example, the assessment and plan could read as follows: Influenza A, X prescribed, call if not improved in X days; make an appointment to return for influenza immunization in about 2 weeks; next visit as needed for new or worsening problem, already scheduled annual wellness visit .

G2211 may also be used in instances where a “patient's overall, ongoing care is being managed, monitored, and/or observed by a specialist for a particular disease condition.” 1 G2211 is an add-on code to the E/M visit, and modifier 25 does not need to be added to the E/M code. (In fact, G2211 cannot be billed if the visit requires modifier 25; see the exclusions section below.) G2211 can be billed with an office visit E/M service provided via telehealth.

EXAMPLES WHERE G2211 WOULD QUALIFY

A 65-year-old established patient on Medicare whom you have been treating for diabetes, hypertension, and hyperlipidemia presents to your office for a routine check. You order an A1C, comprehensive metabolic panel, lipid panel, and urine for microalbumin, and you adjust the patient's blood pressure medication. This would qualify for a 99214 E/M code as well as the G2211 add-on code because you have an ongoing relationship with the patient.

A 72-year-old patient on Medicare who is new to the practice visits your office to establish ongoing care and also has sinus congestion. This would qualify for an appropriate E/M code as well as the G2211 add-on code. In this example, “the complexity that code G2211 captures isn't in the clinical condition — the sinus congestion.

The complexity is in the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.” 3 The intent to establish ongoing care for this new patient suffices.

A 68-year-old established patient who sees you yearly for a Medicare annual wellness visit and periodically for acute problems presents at this visit with complaint of a cough and concern for influenza. You order a rapid test for influenza and recommend influenza vaccination after the patient recovers from this illness and each season thereafter. This would qualify for an appropriate E/M code as well as the G2211 add-on code because you serve as the continuing focal point for all of the patient's health care.

An endocrinologist has been managing a Medicare patient's uncontrolled diabetes and complications for years, and the patient returns for a recheck. This would qualify for an appropriate E/M code as well as the G2211 add-on code because the physician has an ongoing relationship with the patient that involves care of a “single, serious condition or a complex condition” (diabetes, in this instance).

CMS will not pay for G2211 when the E/M service is reported with modifier 25 (significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service). 4 The intent was to exclude G2211 from instances where minor procedures are performed on the same date as an office visit, which often occurs outside of primary care and does not reflect the visit complexity and ongoing relationship otherwise envisioned by G2211. In those instances, CMS considers the additional work and complexity to be part of the procedure code. Unfortunately, the unintended effect of CMS's decision is to exclude the use of G2211 in primary care when modifier 25 is applicable, such as medication administration (e.g., 96372) or spirometry (e.g., 94010 or 94060) in addition to an E/M service. CMS may make additional clarifications on this issue in upcoming rules as they monitor the use of G2211 and have further discussions with interested parties.

Because G2211 may only be reported in addition to office/outpatient E/M visits (99202-99215), it cannot be attached to Medicare annual wellness visits or transitional care management visits. Complexity is already factored into the work and codes for these visits. G2211 also cannot be added to any non-office-visit E/M codes, such as inpatient, emergency department, nursing home, or home visit codes. G2211 would not be appropriate for most urgent care center visits, given the one-off nature of those encounters.

Additionally, CMS considers G2211 to be inappropriate when the visit “is provided by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature; such as, but not limited to, a mole removal” — unless comorbidities are present or addressed, or unless the clinician has taken (or plans to take) responsibility for ongoing care for the patient. 5

CMS has not clarified in writing whether G2211 can be billed by a physician covering for a colleague who is the patient's ongoing source of care or by a nonphysician provider billing for an acute visit with a patient whose ongoing physician is in the same practice. However, based on statements from CMS staff at a Jan. 24, 2024, Open Door Forum , CMS seems inclined to think of clinicians in the same specialty and same group interchangeably for purposes of reporting G2211. (We will update the online version of this article when CMS publishes more guidance.)

EXAMPLES WHERE G2211 WOULD NOT QUALIFY

A 65-year-old established patient on Medicare whom you have been treating for diabetes, hypertension, and hyperlipidemia presents to your office for a routine check. You order an A1C, comprehensive metabolic panel, lipid panel, and urine for microalbumin, and you adjust the patient's blood pressure medication. You also order injection of a medication reported with 96372. This would qualify for a 99214 but would not qualify for G2211 because adding the injection code, 96372, requires that you add modifier 25 to the E/M code.

A 67-year-old Medicare patient sees you for a subsequent Medicare annual wellness visit. G2211 cannot be added because the proper code for this visit is G0439, a HCPCS code, which is not one of the applicable E/M codes. If you had provided the annual wellness visit in addition to an office/outpatient E/M service, modifier 25 would have been required, which would also disqualify the visit for code G2211.

A 70-year-old Medicare patient sees a gastroenterologist for a screening colonoscopy exam without expectation of an ongoing relationship. G2211 cannot be added as there is no ongoing relationship established (or expected to be established).

G2211 DOs AND DON'Ts

Do use G2211 for:

✓ Office/outpatient E/M visits (99202-99205 or 99211-99215) if you are the “continuing focal point for all needed health care services” for the patient, whether the condition is acute or chronic. (If you are not the continuing focal point, use G2211 only if you provide ongoing care for a serious or complex condition.)

Don't use G2211 for:

✗ Non-office E/M visits,

✗ Urgent care center visits (i.e., one-off visits),

✗ Transitional care management visits,

✗ Medicare annual wellness visits,

✗ Visits requiring modifier 25 (i.e., services that when reported on the same date as an office/outpatient E/M service necessitate adding modifier 25 to the E/M code). Examples:

• Annual wellness visit (G0438-G0439),
• Injection of medication (96372),
• Spirometry, inhalation treatment, or other pulmonary function services (94010-94799),
• Osteopathic manipulative therapy (98925-98929),
• Annual alcohol misuse screening (G0442),
• Annual depression screening (G0444),
• High-intensity behavioral counseling to prevent sexually transmitted infection (G0445),
• Annual, face-to-face intensive behavioral therapy for cardiovascular disease (G0446),
• Face-to-face behavioral counseling for obesity (G0447).

USE IN FAMILY MEDICINE RESIDENCY PROGRAMS

Unlike many other specialty residency programs, where patients may see different residents but the same attending physician who is established with the patient and bills for the visit, family medicine patients may see the same resident but have multiple attending physicians who bill for the visits. G2211 is not included in the primary care exception, so that would suggest that in order to use this code for visits that normally qualify for the primary care exception (straightforward and low complexity medical decision making), the attending physician would also need to see the patient. CMS has offered no written guidance in this area. However, at the Jan. 24 Open Door Forum , CMS staff suggested that guidance may be forthcoming allowing G2211 to be billed with E/M services on the primary care exception list if the resident is serving as the focal point for the patient's care.

Until specific guidance is released, given the intent of CMS to recognize the value of the longitudinal relationship between the physician and patient, the following billing practices seem appropriate. If the patient sees the resident who usually provides their care, then it would seem appropriate to use G2211. This would apply to continuity of care issues or acute issues where ongoing care influences the decision-making. If a resident doesn't usually see the patient for care but is seeing the patient for a continuity-type visit, it would seem appropriate to use G2211, as billing would be submitted under one Tax Identification Number (TIN) for the residency practice. Additionally, this would fulfill the intent of the longitudinal relationship for the practice. It would be important for the resident to document the ongoing relationship they have with the patient or the impact the patient's total health has on the current issue. The attending physician would also need to see the patient and document appropriately. Again, this is simply what seems appropriate given the intent of the code, but we look forward to guidance from CMS.

Medicare's national payment amount for G2211 is $16.05; the actual allowance will vary geographically. This value will be subject to the patient's deductible and coinsurance. A Medicare patient often has a 20% coinsurance; therefore, if this code reimburses $16, the patient will be responsible for $3.20. Practices should be prepared to explain to patients what this additional charge is.

CMS estimates that practices will use G2211 with more than half of office/outpatient E/M services once physicians become familiar with the code. So, assuming you provide 20 visits per day, 200 days per year, and half of your visits qualify for the new code, it could bring in $32,080 per year. Some Medicare Advantage plans may pay for this code, while others may consider the work to already be included in capitation rates or other services paid to the practice. Private insurers' coverage of G2211 will also vary because it is not a CPT code, but a Medicare HCPCS code. Each individual insurer sets its own payment policy, just as each state sets its own Medicaid payment policy.

OVERALL, IT'S A WIN

Although limited by legislative actions and budget neutrality, CMS is recognizing the contribution primary care (and other longitudinal care that consists primarily of E/M services) makes to the overall management of Medicare patients. The visit complexity add-on code, G2211, will be valuable for family physicians. Given that Medicare will be paying less per visit in 2024 because the Medicare RVU conversion factor has decreased by $1.14 per RVU, adding this new code will provide a positive net payment for office/outpatient E/M visits. Practices should check the payment policies of their Medicare Advantage plans and private insurers to determine whether they will be paying for this code.

Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies. 88 FR 78970. https://www.federalregister.gov/d/2023-24184/p-1379

Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies. 88 FR 78974. https://www.federalregister.gov/d/2023-24184/p-1397

How to use the office & outpatient evaluation and management visit complexity add-on code G2211. MLN Matters , 13473. Jan. 18, 2024.

Current Procedural Terminology 2024 Professional Edition. American Medical Association. Appendix A:971.

Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies. 88 FR 78971. https://www.federalregister.gov/d/2023-24184/p-1385

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