ASRA Pain Medicine Update

Cite as: Vorenkamp K. G2211: a new code relevant to the ASRA pain medicine community. ASRA Pain Medicine News 2024;49. https://doi.org/10.52211/asra050124.007.

G codes are established by the Centers for Medicare & Medicaid Services (CMS) through a notice to support a specific need as determined by the agency.¹ G2211 is a recent G code that became active as of January 1, 2024² and has received significant attention. G2211 is an add-on code that can be billed in conjunction with a regular evaluation and management (E/M) new patient or follow up visit. It is important to note that it will not be reimbursed when a modifier 25 is appended to the primary E/M code related to a separate procedure.³ Although not all G codes are established for billing by physicians or qualified healthcare providers, some are assigned a work relative value unit (RVU), and reimbursement can occur through these codes, including G2211. G2211 has seen delays in implementation and has been discussed since prior to 2020. 

The code itself is designed to capture the complexity of an office visit that may otherwise not be accounted for in the traditional E/M codes, and central to the code’s documentation is the need to establish the visit as a “focal point” of all the chronic pain needs of a given patient.³ Specifically, it is also important for physicians to document that the office visit involves continued “medical care related to a patient's single, serious condition, or complex condition.”³ Clearly, this code may not be most appropriate for a straightforward patient, who presents only one time for an injection and does not seek chronic longitudinal pain care, but it may be very appropriate for patients with ongoing chronic pain issues. In other words, the pain physician is serving as their primary provider for their chronic pain in a manner not all that different from the central role of a primary care provider.³ Although this code may be billed largely by primary care physicians, the code does not restrict the specialty or the number of billing occurrences in a set time period.⁴

Given that many pain practices care for patients in a longitudinal fashion and may regularly function as their central pillar of pain care, awareness of this code is important for all pain physicians.

Given this code is still in its infancy, there is a small but growing body of literature that shows how to properly use it.³ There is limited documentation advice from CMS specifically for pain medicine providers, but an analogous example has been provided by CMS that shows it is appropriate for an infectious disease specialist to bill G2211 when discussing the complex management and sense of trust that is developed surrounding a patient who has missed multiple doses of an HIV medication.³ Documentation to support this code should include the longitudinal nature of the care and the central aspect of the patient/physician relationship, diagnoses, and an assessment and plan.³ As one example, one could envision this code being very practical to use for a patient with chronic neuropathic pain after a trauma to an extremity complicated by multiple rounds of debridement and surgery. This patient may have severe and debilitating pain that necessitates monthly visits to coordinate the complex level of care provided to improve pain and function. At the same time, the physician will need to balance medication side effects and consider physical/occupational therapy, psychological, and interventional options.

Reimbursement through Medicare is set at 0.33 work RVUs, which equates to less than approximately $16.00 depending on geographic region,² and not all commercial/private insurers may provide reimbursement for this code. CMS expects nearly 38% of office visit E/M charges to include this add-on code, which explains much of the decrease in the CMS conversion factor to maintain budget neutrality.⁵

Given that many pain practices care for patients in a longitudinal fashion and may regularly function as their central pillar of pain care, awareness of this code is important for all pain physicians. More details will likely emerge on best practices in use and documentation, but these general comments are intended to increase visibility of the code for the wider ASRA Pain Medicine community.

References

1. Centers for Medicare & Medicaid Services. Overview of coding and classification systems. https://www.cms.gov/cms-guide-medical-technology-companies-and-other-interested-parties/coding/overview-coding-classification-systems#:~:text=G%20codes%20and%20M%20codes,II%20code%20should%20be%20issued. Published September 6, 2023. Accessed Feb. 25, 2024.
2. Centers for Medicare & Medicaid Services. Physician fee schedule. https://www.cms.gov/medicare/payment/fee-schedules/physician. Published January 25, 2024. Accessed Feb. 25, 2024.
3. Centers for Medicare & Medicaid Services. How to use the office & outpatient evaluation and management visit complexity add-on code G2211. https://www.cms.gov/files/document/mm13473-how-use-office-and-outpatient-evaluation-and-management-visit-complexity-add-code-g2211.pdf. Published January 18, 2024. Accessed Feb. 25, 2024.
4. Centers for Medicare & Medicaid Services. Physician fee schedule payment for office/outpatient evaluation and management (E/M) visits. https://www.cms.gov/files/document/physician-fee-schedule-pfs-payment-officeoutpatient-evaluation-and-management-em-visits-fact-sheet.pdf. Published January 11, 2021. Accessed Feb. 25, 2024.
5. American Society of Anesthesiologists. CMS finalizes deep cuts to Medicare payments in 2024. https://www.asahq.org/advocacy-and-asapac/fda-and-washington-alerts/washington-alerts/2023/11/cms-finalizes-deep-cuts-to-medicare-payments-in-2024#:~:text=For%20CY%202024%2C%20CMS%20finalized,%25%20for%20G2211%2C%20as%20proposed. Published November 2, 2023. Accessed Feb. 25, 2024.