2024 coding update

News
Article
Contemporary PEDS JournalJune 2024
Volume 40
Issue 06

Pediatricians may eventually realize a significant increase in income by attaching the G2211 code to acute and chronic care visits.

2024 coding update | Image Credit: © 312424698 - © 312424698 - stock.adobe.com.

2024 coding update | Image Credit: © 312424698 - © 312424698 - stock.adobe.com.

This article will detail how a recently activated code, G2211, will increase practice revenue and provider compensation. It may take some time, however, for insurance carriers to begin reimbursing for this add-on code, so pediatricians should be prepared to challenge rejected claims.

The way things were

Prior to 2021, documenting office visit codes was a complicated process, requiring a precise combination of history and exam elements to justify the level of service being billed. However, in 2021 the Centers for Medicare & Medicaid Services (CMS), with guidance from the American Medical Association’s RVS (Relative Value Scale) Update Committee, overhauled our coding system, making it more user friendly.1

In brief, the 2021 guidelines included the following changes:

· Eliminated the history and physical as elements for code selection.

· Gave providers the option of choosing whether documentation is based on medical decision-making (MDM) or time associated with the visit on the date of service.

· Modified the criteria for MDM by removing ambiguous terms, clearly defining important terms and concepts, and redefining data MDM measures.

· Deleted Current Procedural Terminology (CPT) code 99201.

· Created a shorter prolonged services code (99417) that captures provider time in 15-minute increments that should only be used in conjunction with codes 99205 or 99215 when time is the primary basis for code selection.

In addition, the new guidelines increased the work relative value units (wRVU) associated with visits, which produced revenue increases for employed physicians. When the time element is used as an alternative to MDM, the billing process is quite straightforward (Table).

2024 coding changes: activation of G2211

This year, CMS eliminated the time range for assigning a time element for an evaluation and management (E/M) code, replacing it instead with a time threshold. By far the most significant change was the activation of a Healthcare Common Procedure Coding System level 2 code G2211, which was approved in 2021 but was under an implementation moratorium until this year. This is an add-on code for all 99202-99205 or 99211-99215 visits. G2211 rewards providers, including specialists, for providing services associated with the “medical home.” No additional documentation is required to justify billing G2211.

This is a spectacular achievement and one that will generate much discussion and controversy as we begin to attach this code to most of our E/M visits.

According to the CMS, the G2211 code should be used 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.”2

Primary care providers (PCPs) and by extension other providers within the same practice, can use G2211 for a visit that is billed using numeric codes 99202-99205 (new patient) or 99211-99215 (established patient). Because of this, G2211 cannot be billed by urgent care facilities. It should not be used for well child visits and cannot be used when a procedure is performed during an E/M visit when the –25 modifier is used, such as when a vaccination is given at a visit. As an example, it is appropriate to attach G2211 to a bill when seeing a patient for a cough. The inherent complexity of G2211 is not in the clinical condition, but rather the cognitive load of the continued responsibility of being the focal point for all needed services for the patient. The physician may need to provide an excuse note for daycare or school, reevaluate the patient should the patient develop wheezing, or the cough persists, order an x-ray, or make referrals to otolaryngology or pulmonology should the cough linger.

Many have criticized the language used to describe the G2211, focusing on the phrase “ongoing care related to a patient’s single, serious condition or a complex condition.”

Note that insurance companies may interpret the phrase as implying that it can be used only for “serious” conditions (subject to interpretation), while the comma, often used to separate elements of a list, also suggests it should be used for an 1) acute, 2) serious, or 3) complex (ie, chronic) condition.

Adult providers may not appreciate how complicated a routine pediatric problem can be. An example is otitis media. First, otitis media can be associated with pain, fever, and vomiting. Persistent otitis media, especially in a young child, can be associated with prolonged hearing deficits that may impact language acquisition. In some situations, such children undergo an audiologic assessment and are referred to an otolaryngologist, as tympanostomy tube insertion might be indicated.

Going forward

The American Academy of Family Practice (AAFP) has included articles relating to implementing G2211 in their official publication anticipating insurance pushback against reimbursing for this code.3 Additionally they are facilitating challenging insurance rejections by providing a template letter on their website as well as educational videos relating to utilization of this new code.

As of this writing (late March 2024), the American Academy of Pediatrics has not produced a position statement and a suggested mechanism for pediatricians to challenge rejected claims. They will likely do so in there very near future, probably before publication of this article.

According to the American Medical Association, G2211 is reimbursed nationwide at $16.05, so including the code will not add substantially to a visit bill. It is also associated with a 0.33 wRVU, which will be appreciated by employed physicians who are traditionally paid less than physicians who own their practices. I have done some simple math, and I anticipate that if the G2211 is universally paid, at minimum, it will result in a $20,000 per year salary increase for both independent and employed physicians. It’s a small increase but one that is long overdue and worth fighting for.

Chip Hart, who developed the Physician’s Computer Company’s pediatric electronic health care record, is monitoring payments for G2211. To date, insurers, including Medicaid, are reimbursing about 10% of claims that include this code and are paying about $19 when billed. The AAFP website indicates that, so far, Cigna (Medicare only), United Healthcare, and Humana are paying for this code.

I suggest all pediatricians immediately begin using this code appropriately and challenge all rejected claims. By doing so, we will, over time, convince insurance companies of the importance of our role in providing patients a medical home.

Click here for more from the June issue of Contemporary Pediatrics.

References:

1. American Academy of Pediatrics. Office E/M 2021: examples of pediatric medical decision-making for office evaluation and management services. AAP Pediatric Coding Newsletter. 2021;16(4):9-11. https://publications.aap.org/codingnews/article-abstract/16/4/9/27418/Office-E-M-2021-Examples-of-Pediatric-Medical

2. Medicare and Medicaid programs; CY 2024 payment policies under the Physician Fee Schedule and other changes to part b payment and coverage policies; Medicare Shared Savings Program requirements; Medicare Advantage; Medicare and Medicaid provider and supplier enrollment policies; and Basic Health Program. Fed Regist. November 16, 2023. Accessed May 13, 2024. https://www.federalregister.gov/documents/2023/11/16/2023-24184/medicare-and-medicaid-programs-cy-2024-payment-policies-under-the-physician-fee-schedule-and-other

3. Weida TJ, Weida JA. G2211: Simply getting paid for complexity. Fam Pract Manag. 2024;31(2):6-10.

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