As of January 1, 2024, Medicare (CMS) will implement new edits to prevent payment of the complexity add-on HCPCS code G2211 when associated with an office and outpatient (O/O) evaluation and management (E/M) visit reported with Modifier 25. This change, outlined in CMS’s recent document Change Request (CR) 13272, has significant implications for dermatology billing practices.
Understanding G2211
G2211, a notable addition to the Medicare Physician Fee Schedule, focuses on extended assessment and management services in dermatology. It requires careful consideration and adherence to documentation guidelines.
G2211 is designed to capture the complexity of a provider’s ongoing relationship with a patient, particularly in managing chronic or serious conditions. It applies to medical professionals who can bill O/O E/M visits (CPT codes 99202-99205, 99211-99215), including dermatologists, provided they are the focal healthcare provider for the patient’s condition.
When to Bill G2211
- The provider is managing a serious or complex problem.
- The provider is the main healthcare provider for that condition.
- The relationship involves significant time and effort over a long period.
For dermatology, conditions like psoriasis or acne often qualify. Managing these conditions involves medication management, testing, continuous monitoring, and handling flare-ups, establishing a long-term relationship with the patient.
Key Considerations
Billing G2211 depends on meeting specific criteria, including extended face-to-face time with patients beyond usual encounters. Practices must ensure accurate coding and documentation to avoid claim denials.
Modifier 25 and G2211
Medicare rules stipulate that G2211 cannot be billed if Modifier 25 is appended to the E/M visit. If G2211 is added to an E/M-25, it will be denied.
| Examples | If a patient has acne surgery (CPT 10040) or an acne cyst drained (CPT 10060) on the same visit, G2211 cannot be billed. |
If a psoriasis patient receives an injection during the visit, G2211 cannot be billed. | |
Any procedure requiring Modifier 25 to show a separate E/M service disqualifies the use of G2211. |
Financial Implications
- The RVUs for G2211 for 2024 are 0.49, with an average participating fee of $15.89.
- G2211 can be appended to both new and established E/M codes, reflecting the ongoing and complex nature of the care provided.
Practical Steps for Dermatology Practices
Documentation Requirements
Documentation to support reporting HCPCS code G2211 must indicate a medically reasonable and necessary reason illustrating the medical necessity for the O/O E/M visit. CMS has indicated that medical reviewers may use the medical record documentation to confirm the medical necessity of the visit and the accuracy of the documentation of the time spent by the dermatologists acting as the focal point of care, including the diagnosis, dermatologist assessment, and plan for the encounter.
Examples of Proper and Improper Use
Proper Use
Dermatology practices should bill G2211 when extended evaluation and management services are provided distinct from other services on the same day.
| Example 1 | A 46-year-old female with psoriasis vulgaris requires ongoing management involving medication management of topical and/or systemic medication to control flares and coordination with other specialists indicating the complexity and longitudinal relationship with the patient, supporting the use of G2211. |
| Example 2 | An established 25-year-old male patient presents with severe acne since his teens, including acne scarring and acne cysts on his face, chest, and upper back. Management of his condition has involved numerous medications that have failed. It is now decided to initiate Accutane, which requires monthly lab tests and managing side effects. This ongoing management supports the complexity and longitudinal relationship required for reporting G2211. |
Improper Use
Billing G2211 without meeting extended service criteria or failing to document the necessity of prolonged evaluation may lead to claim rejections or audits.
| Example 3 | An established patient with psoriasis is treated and a PDT treatment is provided on the same day. Although the dermatologist is the focal point for the patient’s care the same-day procedure disqualifies the use of G2211 with Modifier 25. |
| Example 4 | An established patient seeking monthly evaluation is seen for blood work. He has an enlarged acne cyst on his chest that is lanced and drained billing CPT code 10040. In this case G2211 should not be reported because the procedure (CPT 10040) disqualifies the use of G2211 when billed with Modifier 25 on the same visit. |
| Example 5 | A new patient with acute contact dermatitis is treated with medication and scheduled for follow-up. The acute and self-limited nature of the condition does not justify G2211 which is meant for chronic ongoing care. |
Skin Cancer Monitoring
Long-term monitoring for skin cancer recurrence and metastasis requires a longitudinal relationship and regular visits, justifying G2211 for active monitoring office visits for patients with a history of invasive melanoma.
Considerations Moving Forward
This discussion underscores the importance of aligning billing practices with CMS guidelines and updates from the American Medical Association (AMA). As Medicare continues to refine the Physician Fee Schedule, staying informed about changes in conversion factors and procedural coding is essential. Practices must maintain ongoing compliance with healthcare common procedure coding system (HCPCS) to avoid penalties and optimize revenue.
The new CMS edits challenge dermatology practices to refine their billing practices, enhance documentation, and ensure financial stability. Staying informed and proactive will be key to navigating these changes successfully.
For more details, refer to CMS resources or MLN Matters: MM13473. For further insights into efficient billing practices and compliance, consider reading related articles on maximizing dermatology practice revenue, effective documentation for dermatology billing, and understanding Modifier 25 in dermatology.
Navigating Medicare edits such as G2211 requires proactive measures and adherence to documentation standards. By integrating these insights into daily operations, dermatology practices can enhance billing accuracy, streamline reimbursement processes, and maintain compliance with evolving regulatory requirements.
External Links:
CMS TRANSMITTAL 12461
CMS G2211 OFFICE/OUTPATIENT E/M
Read more from our published resources:
MAXIMIZING PROFIT FOR MOHS SURGEONS
CODING AND DOCUMENTATION GUIDANCE FOR MOHS SURGERY REIMBURSEMENT
UNDERSTANDING THE ROLE OF MODIFIERS IN MEDICAL BILLING
Experience Excellence with Inga Ellzey
With nearly three decades of refining billing processes, Inga Ellzey remains the foremost authority in dermatology billing nationwide. Our billing service supports over 100 dermatology practices across 37 states, distinguishing itself by maintaining operations entirely within the United States, without utilizing offshore labor. Our mission is to deliver unparalleled professionalism and competence to our clients and their patients.
If you’re seeking to optimize your revenue collections and streamline your practice’s processes, we invite you to connect with us. Contact us today at 888-434-4374 to discuss how our expertise can benefit your practice.
