CMS: How to properly report the E/M add-on G codes

February 15th, 2021 / By Barbara Aubry, RN

Hopefully, everyone is using the new E/M codes without issue. CMS added two HCPCS codes to represent “additional” time for E/M services. These are important qualifiers, as medical necessity audits are likely to follow. The latest instructions from CMS on proper use of the G codes:

“When the practitioner selects a visit level using time, the practitioner may report prolonged office/outpatient E/M visit time using HCPCS add-on code G2212 (Prolonged office/outpatient E/M services). Practitioners should not report prolonged office/outpatient E/M visit time using CPT codes 99354 and 99355 (Prolonged service with direct patient contact), 99358 and 99359 (Prolonged service without direct patient contact), 99415 and 99416 (Prolonged clinical staff services), or 99417 (Prolonged office/outpatient E/M services with or without direct patient contact)

HCPCS code G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services). (Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes)” (Underlining is my addition.)

Even though CMS instructs providers to use G codes, there will be no additional payment for G2211 until January 1, 2024 or later; it is currently considered a “bundled” service. The CMS advisory includes a lengthy explanation of this determination, which I encourage readers of this blog post to review in full. Below are a few excerpts that I would like to highlight. According to CMS:

  • The Consolidated Appropriations Act delays PFS payment for this code until January 1, CY 2024 or later. Practitioners may report this code for qualifying visits furnished on or after January 1, 2021, although we assigned a PFS payment status indicator of “B” (Bundled) until 2024.
  • HCPCS code G2211 may be reported with any visit level
  • We do not expect reporting of HCPCS code G2211 when the office/outpatient E/M visit is reported with payment modifiers such as a modifier -24, -25 or -53.

My Take

Trying to become comfortable with new codes is always a challenge and these added requirements are a bit confusing.

HCPCS G2212 (for CMS patients) is reported only in addition to CPT 99205 and 99215. Fifteen minutes extra time is required to report one unit of G2212. If the provider spends less than 15 additional minutes, do not report G2212. If the provider spends 30 additional minutes with the patient, report two units of G2212. If the provider spends an additional19 minutes (or any value less than double or triple (etc) 15 minutes) with a patient, report only one unit of G2212. Thirty-five minutes with a patient would be reported as two units of G2212, etc.

Even though G2211 is considered bundled and not separately reimbursable until at least 2024, it is important to report it on claims with a zero charge. CMS uses claim’s data to make future reimbursement and fee schedule decisions, so it is always important that codes such as this make it into the data base. It appears CMS may be using this add-on code to document care that includes use of “care teams” including use of community resources to meet “social determinants of health,” such as access to reliable transportation. CMS is warning that use of G2211 is not expected on claims containing modifiers 24, 25 and 53. If this is not an edit in the software system you use, speak with your vendor and ask that it be created for Medicare claims only.

Finally, CMS warns;

“MEDICAL REVIEW WHEN PRACTITIONERS USE TIME TO SELECT VISIT LEVEL Our reviewers will use the medical record documentation to objectively determine the medical necessity of the visit and accuracy of the documentation of the time spent (whether documented via a start/stop time or documentation of total time) if time is relied upon to support the E/M visit.”

“Forewarned is forearmed” as they say. Expect audits of all E/M claims that use time as the determining factor in choosing a code. MACs may be instructed to focus on specific codes or diagnoses, or even specific extra time units reported. Since E/M services are such a large volume of the claims processed, CMS may choose to hire outside auditors.

This reminds me a bit of the medical necessity audits for one-night stays and all the challenges of that time. It is always important to properly document, but when a medical necessity audit is looming, be sure to include information that supports the decision making process.  As we learn more, we will continue to provide updates on this important topic.

Barbara Aubry is a senior regulatory analyst with 3M Health Information Systems.

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