MAY 06, 2024
How Do We Document Visit Complexity When Billing G2211?
What documentation is needed to meet the definition of G2211?
Answer:
The physician must clearly document the collaborative care plan for each unique patient encounter for a single, serious complex condition. Collaborative care includes patient education, expectations and responsibilities, shared decision-making around therapeutic goals, and shared commitments to achieve those goals. The primary focus is the ongoing care and long-term relationship between the physician and the patient. Health Care Common Procedure Coding System (HCPCS) code G2211 is not billable for conditions that will resolve with treatment or surgery or are limited in nature (e.g., acute conditions). The managing physician bills it, not for a one-time consultation.
Access the Academy’s Fact Sheet at HCPCS Code G2211 Visit Complexity Add-on Code