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Deepening ongoing physician concerns over the implementation of Medicare’s add-on code for complex care, two major payers have either reduced payment for G2211 claims or announced plans to stop paying certain claims associated with the code altogether for particular plan members.
The 2024 Medicare Physician Fee Schedule allows physicians to list G2211 to indicate additional work they undertake to provide comprehensive and continuous care to patients with complex conditions or one serious condition. The 2024 Medicare allowable amount for G2211 varies geographically but is usually either $16.04 or $15.88 in Texas.
Exacerbating payment uncertainty, however, UnitedHealthcare (UHC) will no longer pay claims with G2211 for services rendered to commercial plan members beginning Sept. 1. Texas Medical Association experts also have learned Aetna is not paying the full allowable amount.
Per UHC’s June 2024 policy update, the payer will still pay for services associated with G2211 if they are related to outpatient evaluation and management (E/M) services provided to Medicare Advantage plan members. TMA Director of Reimbursement Services Carra Benson explains that under the policy update, UHC will pay Medicare plans separately, while claims for commercial plan holders will be denied with an indication from UHC that the payment is bundled into the primary E/M services.
Previously, United covered the code for services provided to all Medicare Advantage plans and commercial plan members.
While the move aligns with guidelines from the Centers for Medicare & Medicaid Services on the code, it also has the potential to cause payment frustration for physicians who provide comprehensive care to patients with complex conditions, says Ms. Benson.
TMA also has learned that Aetna is erroneously paying only one cent to physicians for G2211 claims. Ms. Benson says the error has led multiple physicians to reach out to TMA’s Physician Payment Resource Center, whose experts work directly with payers to resolve payment issues.
TMA coding experts are working with Aetna to ensure physicians receive appropriate payment for the care they provide. Ms. Benson says the payer is in the process of updating its fee schedule to fix the issue. Once that is complete, Aetna representatives have told TMA they will rework claims with G2211 to ensure the full allowable amount is paid.
In the meantime, Ms. Benson says practices should continue to file G2211 codes as usual and maintain detailed records of all communication with Aetna.
TMA experts recommend physicians use G2211 when:
- They have assumed or intend to assume responsibility for the patient’s ongoing medical care; and
- Their visits with the patient are routine or time limited. For example, a physician who sees a patient for an acute concern should not report G2211 if they have not also assumed responsibility for the patient’s ongoing medical care or do not plan to take responsibility for subsequent medical care.
For more information on billing and coding, visit TMA’s comprehensive Physician Payment Resource Center.
Alisa Pierce
Reporter, Division of Communications and Marketing
(512) 370-1469