Understanding the New “Complexity” Code G2211

Here’s what you need to know about Medicare’s new “complexity” code that started in 2024. You may have heard of this code but may not know the details. In this article, we explain the most common questions doctors have.

When to Use Code G2211?

Starting January 1, 2024, some doctors can use a special code called G2211. This code shows extra time and work needed to care for Medicare patients with serious or complex health problems.

What G2211 Means?

G2211 is used when a doctor:

• Gives ongoing care for all of a patient’s health needs.
• Helps a patient with one serious or complex condition.
• Bills it with another office or outpatient visit code.
• Can also bill it for telehealth visits.

Important Rules

Do not use G2211 if:

• The doctor only sees the patient once (like urgent care or second opinion).
• The visit includes another procedure billed with modifier 25.
• A complex condition is written down but not treated or talked about.

Doctors who can use it:

• Primary care doctors.
• Specialists who care for patients long-term.

Example

Dr. Smith sees a patient with complex health problems.

• Bills 99214 for the office visit.
• Adds G2211 because he gives ongoing care.
• No other treatment (like chemo) was done that day.

Do’s and Don’ts

Do’s

• Check if this service fits your specialty.
• Keep clear notes for billing.
• Update billing systems.
• Teach providers about it.
• Review new claims to stay compliant.

Don’ts

• Don’t bill G2211 for every visit.
• Don’t forget: it is for long-term care and better patient outcomes.

Why It Matters?

CMS (Medicare) now pays more for the mental work doctors do.

• G2211 pays $16.04 per visit.
• It adds 0.33 work RVU.
• CMS expects 38% of visits in 2024 will use G2211.
• This code can help balance payment cuts in 2024.

What is the new code?

The new code is called HCPCS +G2211.

This code is for visits that are more complex. It is used when:

• A doctor is the main provider for all of a patient’s health needs.
• A doctor is helping with a serious or complicated health problem.

It is an “add-on” code, which means it is used with another office or outpatient visit code. Medicare introduced this code in 2021, but it only started on January 1, 2024. The current payment for it is $16.04.

Private insurance companies do not have to pay for this code. Their rules may be different.

The AMA (American Medical Association) and many surgical groups did not support this code. Why? Because adding it caused a 2.18% cut in the 2024 Medicare payment formula.

When is this code used?

The CMS Fact Sheet says this code is for doctors who have long-term care relationships with patients.

This means:

• It’s not only for people with one disease or high-risk problems.
• It is for doctors who give care for most of a patient’s health needs.
• Care should be personalized to the patient.
• The doctor and patient should have an ongoing relationship.
• Care should be team-based and coordinated with other providers.

In specialty care, this code may be used if the doctor:

• Teaches the patient about their condition.
• Shares decisions about treatment goals.
• Works with the patient over time to reach those goals.

Can eye doctors use this code?

Eye doctors (ophthalmologists) are not banned from using this code. But in most cases, they won’t use it often. To use it, the medical record must show more than just a long or detailed visit.

Example case:
A neuro-ophthalmologist sees a 41-year-old woman who lost vision in both eyes three days ago. She had a similar problem a year earlier that improved with strong oral steroids. Recently, she also had headaches and trouble sleeping. The doctor ordered several tests: blood work, MRI, OCT, and VEP.

At today’s visit, her vision is only light perception in both eyes. The doctor diagnoses optic neuritis from multiple sclerosis and recommends IV steroids. After the visit, the doctor talks with her neurologist. They consider interferon therapy. The neurologist admits her to the hospital for IV steroids.

The outpatient visit is billed with 99215 and +G2211. The hospital admission by the neurologist cannot be billed with +G2211.

This shows how the code works when doctors manage a patient’s care plan over time as part of a team.

CMS also explains that this code is not the same as care management. Care management is for services outside the visit, but this code is for the extra work during the visit.

The American Academy of Ophthalmology says +G2211 should not be used for:

• Short-term problems like eye injuries, allergies, or conjunctivitis.
• Visits that only lead to surgery, like cataract removal.
• Cases where there are no other health issues, or the doctor is not giving long-term care.

Which visit codes work with +G2211?

+G2211 can only be used with office or outpatient E/M visit codes.

It cannot be used with:

• Inpatient E/M services
• Eye codes (920xx)
• Code 99211
• Any E/M code billed with modifier -25

Who can use this code?

All doctors can bill +G2211. But CMS expects primary care doctors to use it the most, because they usually have long-term relationships with patients.

Surgical doctors will use it the least, since their care is usually short-term. Specialists may use it sometimes, but not as often as primary care.

CMS also said “primary care specialties” do not include ophthalmology or optometry.

For this reason, eye doctors are expected to use this code only rarely. Using it too often could raise concerns and lead to audits.

+G2211 is a new Medicare code for complex visits that involve long-term care and strong doctor-patient relationships. It is mainly for primary care doctors. Eye doctors are not expected to use it often.

Who Is Allowed to Bill It?

• Primary care doctors may use it.
• Specialists who take responsibility for ongoing care may also use it.
• Doctors providing short-term or one-time care should not use this code.

Example in Practice

A specialist, Dr. Smith, sees a patient with several ongoing health conditions.

• He bills 99214 for the office visit.
• He also bills G2211 because he manages the patient’s long-term care.
• No extra procedures were done that day, so no modifier 25 is used.

This is the correct way to report G2211.

Pro’s and Con’s

Pro:

• Make sure the service is right for your specialty.
• Keep detailed notes to show why G2211 applies.
• Update your billing system and train your staff.
• Review and audit claims for accuracy.

Con’s:

• Don’t automatically attach G2211 to every visit.
• Don’t forget that the code is meant to show ongoing care and care planning, not just a one-time service.

Why This Code Matters?

Medicare understands that doctors spend time thinking, planning, and coordinating care that isn’t always visible. G2211 helps cover that effort.

• The code pays $16.04 per use.
• It carries a work RVU of 0.33.
• Medicare expects that about 38% of office visits in 2024 will include this code.
• It may help offset lower payment rates set for 2024.

Conclusion

G2211 is not just another billing code. It is a way to make sure doctors are recognized for the long-term care and decision-making they provide for patients with complex needs. Use it carefully, document clearly, and apply it only when it truly fits.