What is the status of chronic condition code G2211?

January 22, 2021
Jonathan Rubenstein, MD

,
Mark Painter

Mark Painter is CEO of PRS Urology SC in Denver.

Recent legislation appears to have delayed implementation of the new code.

I read that G2211 was delayed by 3 years. Can you explain?

The 2021 Medicare Physician Fee Schedule (MPFS) Proposed Rule included the new Healthcare Common Procedure Coding System (HCPCS) add-on code GCP1X, used to better describe the work associated with visits that are part of ongoing, comprehensive primary care, and/or visits that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. This code could be used by specialists such as urologists who manage complex chronic conditions and may be added to any outpatient evaluation and management service level (99202-99215). This code was resequenced as G2211 in the final rule, released on December 1, 2020.

Code G2211’s description reads, “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.” This code was valued at 0.33 work relative value units, with a payment of around $16. However, on December 27, 2020, the Consolidated Appropriations Act was passed, which made a number of changes, including a 3.75% increase in MPFS payments for the calendar year 2021, a continued suspension of the 2% payment adjustment (“sequestration”) through March 31, 2021, and a delay of implementation of the G2211 until 2024.

What does this mean? Due to the sheer volume of use of G2211 that was expected to be utilized by providers, these dollars went back into the conversion factor. The Centers for Medicare & Medicaid Services (CMS) therefore recalculated the conversion factor to $34.89. This updated conversion factor represents a 3.3% drop instead of the 10.2% drop included in the final rule. Those who were expected to be significantly impacted by the greater than 10% drop in the conversion factor, such as those who provide a significant number of surgical procedures over office visits, were subject to a reprieve. Urology as a specialty is not expected to be adversely expected. The American Medical Association has projected the same 8% increase in overall revenue for urology in 2021 over 2020. CMS had not yet issued its projections at the writing of this article.

Medicare released an updated relative value unit (RVU) file on December 29, 2020, and an updated RVU file on January 5, 2021. Code G2211 was not included in either file. At this point, we would take this to mean that reporting G2211 will not only result in no payment for the code, but the claim may be rejected considering code G2211 as not valid. The code G2211 is, however, included in the most recent HCPCS file, released on January 3, 2021, so it may not block processing. We would recommend not submitting code G2211 to be safe.

Send coding and reimbursement questions to Rubenstein and Painter c/o Urology Times®, at urology_times@mmhgroup.com.

Questions of general interest will be chosen for publication. The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.