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By Adam Safdi, WCI Columnist
Did I get your attention with that headline?
Are you a clinic/office-based pediatrician, internist, or other specialist who works in the US and who develops ongoing relationships with your patients in a clinic/office setting (referred to collectively as “clinicians” for the remainder of this column)? Do you ever wish that clinicians made as much money as surgeons or other doctors who perform procedures (referred to collectively as “surgeons” for the rest of this column)?
(I fully recognize that surgeons see patients in clinic, too, and some develop longitudinal relationships with their patients. Please permit me this contrasting false dichotomy for the sake of this column.)
Are you doing your best to be a good clinician and develop meaningful longitudinal relationships with your patients so that you can care for them well? Do you experience burnout? Do you, as a mid-career clinician, sometimes look at WCI articles of doctor salaries and wish you had picked a procedure-based specialty so you could earn more money? Are you a third- or fourth-year medical student preparing to apply for residency who finds fulfillment in clinician work and is considering a residency aimed toward primary care, but you worry about what your future salary will be compared to those who pick surgery? Are you depressed or angry about cuts to reimbursement for outpatient/office-based visits?
Imagine yourself as a mid-career clinician being offered a $10,000-$70,000 raise just for being a good clinician. Or imagine being a third- or fourth-year medical student and suddenly learning that clinicians can make more money than previously reported. Would that make you happier and possibly make you feel more valued as a clinician? Would it level the playing field between clinicians and surgeons?
OK, enough with the infomercial talk. Let’s get serious. CMS (Centers for Medicare & Medicaid Services) implemented a new billing code (established on January 1, 2021, delayed until January 1, 2024, and implemented on February 19, 2024) that has a chance to help clinicians earn more money.
I’m talking about the G2211 add-on code, more formally known as the Office and Outpatient (O/O) Evaluation and Management (E/M) Visit Complexity Add-on Code G2211.
Disclaimer: I am not a medical billing or coding expert. I welcome further clarifications and feedback in the comments. This information is being provided for educational purposes only, and I encourage you to talk more with your medical coding and billing specialists about your specific situation.
What Is G2211?
CMS describes the G2211 code as a “visit complexity inherent to evaluation and management associated with the medical care services that serve as the continuing focal point for all needed healthcare 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. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established).” [Added emphasis is mine.]
What does it mean to be an add-on code? When you are a clinician, you probably use the following billing codes very frequently: 99202, 99203, 99204, and 99205. These are codes used for new patient visits, with the higher numbers—99212, 99213, 99214, 99215—representing more complex visits. G2211, when used, is added on to these codes when submitted for billing. In other words, both 992xx and G2211 are submitted for reimbursement.
More information here:
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Why Was G2211 Created?
It is meant to reflect the resources, such as time and intensity, that are involved when clinicians provide office-based visits that build longitudinal relationships with patients. The G2211 code helps to better account for the resource costs associated with visit complexity inherent to longitudinal care and primary care.
Who Can Bill G2211?
Any specialty can bill for G2211; you just need to document that there is a longitudinal relationship. While any specialty can bill for G2211, it is expected that internal medicine and family medicine will likely be the top billers. G2211 can be billed in the office, with telehealth in the patient’s home, or with telehealth outside the patient’s home.
Can G2211 Be Billed with New Patients?
Yes, as long as you document a plan for a longitudinal relationship.
How Much Does This Add-On Code, G2211, Pay?
The best answer I found comes from the American Academy of Family Physicians, which says the 2024 national Medicare allowable for G2211 is $16.05. Other sources relate that G2211 has a work RVU of 0.33 and a total RVU of 0.49. My hospital system is still working with a pre-2024 Physician Fee Schedule (PFS), so I wish I could confirm these numbers for you from my own experience, but I cannot.
More information here:
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How Much Money Can You Make with G2211?
Let’s say you are a full-time clinician working 45 weeks per year, five days a week, seven working hours per day. Let’s assume you see between 20-28 patients per day. For simplicity, let’s assume you currently have, or will develop, a longitudinal relationship with 20 of those patients. That adds up to 20 x 5 x 45 = 4,500 visits per year. If you successfully use the add-on code G2211 for all of those visits, that could be 4,500 x $16.05 = $72,225 worth of extra salary per year.
That is a lot of extra money for being a good doctor and doing a little extra documentation. This amount would obviously become lower if you don’t work full time or if you don’t develop long-term relationships with patients (such as working in urgent care) or for other exceptions noted below (which is why the headline shows such a range of possible additional income).
I also recognize that this G2211 add-on code wasn’t created in isolation. It came along with cuts in the 2024 PFS by way of a lowered conversion factor for reimbursement. In fact, the 2024 conversion factor is the lowest it has been since the 1990s. So, if you adopt the 2024 PFS, a drop in reimbursement will slightly undercut the gain in reimbursement from this G2211 add-on code. Furthermore, adopting the 2024 PFS in an entire medical system could negatively affect reimbursement for non-clinicians, such as surgeons, ER doctors, radiologists, and other specialties that do not develop longitudinal relationships.
This reduction in the conversion factor was explained in a CMS publication as follows.
“By factors specified in law, overall payment rates under the PFS will be reduced by 1.25% in CY 2024 compared to CY 2023. CMS is also finalizing significant increases in payment for primary care and other kinds of direct patient care.
The final CY 2024 PFS conversion factor is $32.74, a decrease of $1.15 (or 3.4%) from the current CY 2023 conversion factor of $33.89.”
There are other notable exceptions to using G2211:
You cannot bill a procedure AND an E/M code with modifier 25 AND bill G2211. You cannot bill for 992xx AND smoking cessation counseling (99406 (3-10 minutes) or 99407 (greater than 10 minutes)) on the same visit as G2211. You cannot bill for G2211 in addition to annual wellness visits (G0428 or G0439). You cannot bill for G2211 in addition to Transitional Care Management (TCM) visits (99495 and 99496). You cannot bill for G2211 if there are no plans for a follow-up appointment. Anecdotally (from my coding and billing experts), I have heard that a follow-up appointment must be recommended for less than or equal to one year in the future.There are documentation rules for billing G2211. The medical record must support that there is a patient and provider relationship. There must be claims history for established patients. Documentation for a new patient visit must show in the assessment that there are plans to start a longitudinal relationship (ie. plan to follow up Hemoglobin A1c or blood pressure in x months; repeat x test x weeks after starting x medication). You can document the trajectory you believe your recommended treatment will take. You can document knowledge of a past drug trial as a reason for prescribing a different drug. A “dot phrase” may not be used to assert that one has a long-term relationship with a patient (this is according to a presentation given to my group by our coding/billing experts).
G2211 Examples
How about some examples? I really like these examples directly from the CMS publication, and I will attempt to summarize them afterward.
“Example 1: A patient has a primary care practitioner that is the continuing focal point for all healthcare services, and the patient sees this practitioner to be evaluated for sinus congestion. The inherent complexity that this code (G2211) captures is not in the clinical condition itself—sinus congestion—but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient. There is previously unrecognized but important cognitive effort of utilizing the longitudinal relationship itself in the diagnosis and treatment plan and weighing the factors that affect a longitudinal doctor-patient relationship. In this example, the primary care practitioner could recommend conservative treatment or prescription of antibiotics. If the practitioner recommends conservative treatment and no new prescriptions, some patients may think that the doctor is not taking the patient’s concerns seriously and it could erode the trust placed in that practitioner. In turn, an eroded primary care practitioner/ patient relationship may make it less likely that the patient would follow that practitioner’s advice on a needed vaccination at the next visit. The primary care practitioner must decide what course of action and choice of words in the visit itself would lead to the best health outcome in this single visit, while simultaneously building up an effective, trusting longitudinal relationship with this patient for all of their primary health care needs. Weighing these various factors, even for a seemingly simple condition like sinus congestion, makes the entire interaction inherently complex, and it is this complexity in the relationship between the doctor and patient that this code captures.
Example 2: a patient with HIV has an office visit with their infectious disease physician, who is part of ongoing care. The patient with HIV admits to the infectious disease physician that there have been several missed doses of HIV medication in the last month. The infectious disease physician has to weigh their response during the visit—the intonation in their voice, the choice of words to not only communicate clearly that it is important to not miss doses of HIV medication, but also to create a sense of safety for the patient in sharing information like this in the future. If the interaction goes poorly, it could erode the sense of trust built up over time, and the patient may be less likely to share their medication adherence shortcomings in the future. If the patient isn’t forthright about their medication adherence, it may lead to the infectious disease physician switching HIV medicines to another with greater side effects, even when there was no issue with the original medication. It is because the infectious disease physician is part of ongoing care, and has to weigh these types of factors, that the E/M visit becomes inherently more complex and the practitioner bills this code (G2211). Even though the infectious disease doctor may not be the focal point for all services, such as in the previous example, HIV is a single, serious condition, and/or a complex condition, and so as long as the relationship between the infectious disease physician and patient is ongoing, this E/M visit could be billed with the add-on.”
Do those examples seem a little subjective? Perhaps. Example 1 essentially boils down to: you are a PCP caring for a patient (i.e. you serve as the continuing focal point for all needed healthcare services), and even if they have a simple complaint (sinus congestion), you know (and document) their pertinent history and why you are choosing one treatment over another—such as explaining that you are avoiding phenylephrine (found in many over-the-counter cold products) in a patient with hypertension or avoiding antibiotics in a patient with a recent history of C. Difficile colitis.
Example 2 boils down to: You are an infectious disease specialist caring for a patient as part of ongoing care related to a patient’s single, serious condition or a complex condition (HIV), and your patient admits to non-compliance with HIV medication. But you respond with empathy (and document) your empathic and encouraging response in order to foster an ongoing relationship with the patient as you attempt to get them back on track with their medication.
More information here:
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Potential Issues with the G2211 Code
Here are some possible hiccups to starting to use the G2211 code now, or getting reimbursed for using it.
As this G2211 add-on code is still new, I expect the medical community to hear more guidance from CMS and coding and billing experts as time goes on. But for now, just know that the G2211 add-on code exists, and if your medical system is using (or will soon start using) the 2024 PFS, this seems like a great opportunity for clinicians to boost their income. I think the intention of CMS is good with the introduction of this code, as it is intended to reward doctors who care for patients long term.
While the first few paragraphs of this article might have sounded a little like an infomercial, I sincerely hope that the use of this G2211 add-on code—and the resulting income boost—increases the happiness and job satisfaction of clinicians working in the US.
Looking to increase your income or renegotiate an existing contract? Hop on over to the WCI physician contract review page, where you can find vetted lawyers and compare your contract to other docs.
What do you think? Have you already been getting reimbursement for the G2211 add-on code? What experiences with the G2211 code do you have that you want to share? Comment below!
The post Clinic-Based Doctors: This One Move Can Make You an Extra $10,000-$70,000 Per Year appeared first on The White Coat Investor - Investing & Personal Finance for Doctors.
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