November 13, 2023

New Medicare Code for Ongoing Personalized Treatment

The 2024 Medicare physician payment schedule unveiled by CMS brings some encouraging developments for primary care in the United States. The long-awaited add-on billing code, G2211, is proposed to take effect on Jan 1, 2024.

However, this crucial policy step toward nationwide healthcare improvement has not been without its share of opposition.

Join us as we delve deeper into the topic and explore code G2211—why it holds significance, who advocates for it, and the reasons behind the opposition.

What's Code G2211?

In 2020, the Centers for Medicare and Medicaid Services (CMS) introduced the Healthcare Common Procedure Coding System (HCPCS) code G2211, initially included in the CY 2021 Medicare Physician Fee Schedule final rule. However, congressional action delayed its enactment until January 1, 2024, citing concerns over extra costs and as a cost-cutting measure during the pandemic.

The HCPCS add-on code G2211 aims to compensate physicians for care coordination and other essential medical care services required to deliver comprehensive, continuous, and longitudinal care for patients with a single severe condition or complex condition. It is expected to be relevant for outpatient office visits as extra compensation, acknowledging the underlying expenses clinicians may face while providing ongoing care for a patient's severe single condition or complex chronic condition.

When G2211 Isn't Applicable?

CMS is currently making policy refinements following feedback from stakeholders and advises that the new add-on code would not be billed with a modifier that denotes an office and outpatient evaluation and management visit that is itself unbundled from another service (e.g., a procedure where complexity is already recognized in the valuation). In other words, HCPCS code G2211 is not intended for use when reporting an office/outpatient E/M visit alongside payment modifiers 25, 24, or 53.

The Role of G2211 in Improving Patient Care

HCPCS code G2211 is a significant leap forward in healthcare, focusing on primary care and chronic condition management.

Primary care is indispensable in the U.S. healthcare system, pivotal in maintaining patient well-being and managing chronic conditions. However, it has often grappled with limited resources, making it challenging to cater to patients with complex conditions effectively. Tochi Iroku-Malize, MD, MPH, FAAFP, President of AAFP, affirms that the longstanding lack of adequate investment in primary care has been a driving force behind our current fragmented, costly, and challenging-to-access healthcare system.

With approximately 6 in 10 U.S. adults dealing with at least one chronic condition, the burden on patients and their families is substantial. G2211's introduction offers a transformative opportunity to address these issues by building longitudinal patient relationships. It provides a means to compensate healthcare providers for the extra effort and time required to manage acute and chronic health conditions. By doing so, it not only empowers primary care but also improves patient outcomes, thus marking a significant milestone in enhancing healthcare delivery in the United States.

Moreover, as stated by Dejaih Johnson, ACP governmental affairs and public policy senior associate, "it will help promote beneficiaries' timely access to primary care and other continuous services that promote better health care outcomes and help reduce spending; advance more appropriate payments for primary care and other longitudinal, continuous care under the Medicare Physician Fee Schedule; and help sustain primary care and other physician practices that Medicare beneficiaries rely on and bolster the physician workforce."

Champions of Code G2211 Adoption

Leading the charge for adopting code G2211 are prominent organizations, including The American Academy of Family Physicians, The American College of Physicians, the Primary Care Collaborative, Primary Care For America, and numerous other healthcare organizations.

Tochi Iroku-Malize, MD, MPH, FAAFP, President of AAFP, emphasized the need for Congress and healthcare leaders to unite and advocate strongly for primary care while prioritizing the health of our nation's seniors. Addressing the historical underinvestment in primary care through policy changes is paramount to advancing healthcare accessibility.

Furthermore, Dejaih Johnson, ACP governmental affairs and public policy senior associate stressed, "ACP has prioritized budget neutrality reform for many years, and we understand the challenges. However, the relief and opportunity provided by implementing G2211 should not be delayed or halted due to a payment system that pits medical specialties against one another. We encourage the House of Medicine to collectively support what are long overdue improvements to primary care and focus efforts on approaching Congress in support of systemic payment reform."

Understanding Opposition to G2211

A coalition of 19 surgical organizations, including the American College of Surgeons (ACS) and the American Society of Anesthesiologists (ASA), have voiced vehement opposition to the introduction of Centers for Medicare & Medicaid Services (CMS) code G2211, expressing concerns about its potentially detrimental impact on surgeons and surgical patients.

They argue that G2211 has become unnecessary due to new coding rules for office visits, allowing flexibility in billing higher-level codes. They assert that the abundance of existing codes for documenting work and time across different care levels makes G2211 redundant.

Additionally, they express concerns that G2211 would overpay family physicians and penalize all physicians by reducing the Medicare conversion factor (a proposed 3.36% cut in the 2024 Medicare Physician Fee Schedule). This adjustment is made to uphold the budget neutrality rule, which mandates that CMS cannot boost payments in one segment of the physician fee schedule without offsetting reductions in another segment.

The ASA believes that CMS's intention to implement the code in a budget-neutral manner will likely result in corresponding reductions in Medicare payments for anesthesia, pain management, critical care, and surgical specialties.

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