Round Rock family medicine physician Tina Philip, DO, routinely cares for patients with complicated, chronic needs and regularly checks for new codes or updates that could boost her solo practice’s revenue for that effort. However, she often finds that health plans are slow to provide guidance on how to bill for such care, making payment a “mixed bag.”
For instance, Dr. Philip was hopeful the new Medicare add-on code G2211 would provide physicians with more accurate payment for complex visits. While it has proved useful in some circumstances, she finds implementation lacking.
“Some of my G2211 claims are getting paid, while some are not,” she said. “And I’m not doing anything differently between one claim or the other. I’ve been asking payers for more information, but it’s still up in the air. I don’t know what the secret is to get all my claims covered.”
She is optimistic, however, that the G-code and others that compensate physicians for complex patient care – such as care coordination and chronic care management codes – will help increase her practice’s revenue while increasing her patients’ access to care.
“Additional payment is a start,” she said. “At the end of the day, primary care physicians are already providing high-quality care for our patients’ complex conditions. Learning these codes can help us be fairly compensated and keep our doors open to care for our patients.”
The Texas Medical Association regularly meets with Texas payers to advocate on physicians’ behalf and help resolve payment policy problems.
New codes present new challenges, says TMA Director of Reimbursement Services Carra Benson. And even existing codes require sifting through a multitude of billing and documentation requirements that, without clear understanding, can prevent proper utilization and, ultimately, payment.
As physicians continue to face declining payments and rising administrative burdens that can take a toll on practice viability – and access to care – TMA, through its advocacy and payment experts, “is here to help physicians navigate those challenges and get paid on time,” Ms. Benson said.
Dr. Philip stresses that while confusing, proper use of these codes can enhance patient care, promote preventive measures, and support better health outcomes.
Here’s a look at how three types of codes can help physicians get compensated for complicated care.
Care complexity
After a congressionally mandated delay expired in 2024, Medicare began covering the new G2211 add-on code, which aims to recompense physicians for the extra work required for coordinating care for patients with complex or serious conditions.
Private health plan coverage still varies. As of this writing, four national payers had confirmed coverage of G2211:
- Aetna (Medicare Advantage only);
- Cigna (Medicare Advantage only);
- Humana (commercial and Medicare Advantage); and
- United Healthcare (commercial and Medicare Advantage)
And confusion over the code’s use persists, particularly when it comes to documentation.
The relationship between the patient and the physician is the determining factor of when the add-on code should be billed. TMA experts recommend physicians use G2211 when:
- They have assumed or intend to assume responsibility for the patient’s ongoing medical care; and
- They intend to apply the code to office and outpatient evaluation and management (E/M) services.
Physicians should not use G2211 when:
- 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.
- The associated office visit’s E/M service is reported with modifier 25.
The Centers for Medicare & Medicaid Services (CMS) does not restrict G2211 to medical professionals based on specialties and recommends physicians bill the code if they are the continuing focal point for all needed services, like a primary care practitioner, or are giving ongoing care for a single, serious condition or a complex condition, like sickle cell disease or HIV.
TMA also continues to push for additional documentation guidance. For now, CMS guidance states G2211 documentation need only illustrate the medical necessity of the visit and the time physicians spent during the visit. It points to the following items that could serve as supporting documentation:
- Information included in the medical record or in the claim’s history for a patient or practitioner combination, such as diagnoses;
- The practitioner’s assessment and plan for the visit; and
- Other service codes billed.
Ms. Benson recommends practices update their electronic health record (EHR) and billing systems to reflect the 2024 Medicare Physician Fee Schedule to verify G2211 is added. Practice management or billing and coding staff can help with this.
She also says physicians should be aware that:
- They cannot append modifier 25 when billing for G2211;
- The code can only be listed in addition to codes used in office or for outpatient visits for new or established patients as an add-on with 99202-15;
- G2211 is listed as a code that can be used for telehealth;
- CMS has not defined “complex condition,” meaning physicians should create an internal policy on what complex condition means to them; and
- G2211 claims should not include templates or document patient-specific details.
Chronic care management
Most of Dr. Philip’s Medicare population falls into the two-thirds of Medicare patients CMS says have two or more chronic conditions that require care management and visits on a regular basis. “So, I aim to learn all the codes that can help me recoup payment for that,” she said.
That includes chronic care management (CCM) codes, which allow health care professionals to bill for services provided to patients with two or more chronic conditions or diseases that persist over a long period and put them at risk of significant health decline.
Currently, there are several types of CCM codes dependent on if the physician is the initial point of care clinician, the amount of time a physician or clinical staff member spends with the patient, and the complexity of the service.
For example, 99487 and 99489 may be used for services needed often or regularly that include moderate to high medical decision-making by a practitioner, such as care for a patient who is severely ill. Those codes may be billed by:
- Physicians and certain nonphysician practitioners, like physician assistants, certified nurse midwives, clinical nurse specialists, and nurse practitioners;
- Rural health clinics and federally qualified health centers ; and
- Hospitals, including critical access hospitals.
And each code comes with different billing requirements. CMS recommends practices:
- Obtain the patient’s verbal or written agreement to receive CCM services after informing them of applicable cost sharing and that they can stop receiving CCM services at any time;
- Document patient consent in the patient’s medical record;
- Acknowledge that only one practitioner or hospital can provide CCM services for the patient in a calendar month;
- Establish, implement, revise, or monitor an electronic comprehensive care plan for the patient that tracks their health issues and share it with the patient or their caregiver when appropriate;
- Provide the patient with a way to contact the practice at any time to address urgent care management needs;
- Provide continuity of care for the patient through a designated care team member with whom the patient can schedule appointments and who is regularly in touch with the patient to help them manage their chronic conditions; and
- Record certain data through an EHR, including the patient’s demographics, medical problems, medications, and medication allergies.
Care coordination
Similarly, care coordination codes aim to compensate physicians who treat patients with complex needs and must be seen by multiple clinicians. Dr. Philip says these codes support collaborative care models that increase access in the primary care setting while providing payment for a particular physician’s role in patient care.
According to the American Medical Association, collaborative care models require cooperation between practitioners that doesn’t always fit into previous billing codes, requiring specific coordination codes to recover payment.
These include codes 99424-25 and 99492-94, which again come with their own specific documentation requirements, such as records that indicate a physician’s comprehensive care plan. Per AMA, this plan should include patient consent, a patient’s medical history, and evidence that the practice is providing active collaborative care management by meeting three core components:
- Active treatment and care management for an identified patient population;
- Use of a patient-tracking tool to promote regular outcome monitoring and targeted treatment; and
- Use of a registry to hold regular, systematic caseload reviews.
To avoid confusion, TMA experts recommend physicians properly plan how revenue will be divided among the care team, such as with a care manager or a psychiatric care consultant. For example, if a patient is receiving mental or behavioral health care, some practices pay the psychiatrist for a specified amount of time; others may partner with a behavioral health organization.
Ms. Benson says that sticking to CMS’ guidelines and using codes only when appropriate should “stave off most payment problems.” However, if denials persist, physicians can reach out to TMA payment specialists for more information.