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  • Does a Noncompliant ICD-10 and the Complexity Add-on Code (HCPCS code G2211) Indicate the Same Information to a Payer?

    I often link the ICD-10 code Z91.19 for noncompliance to bill an E/M level 4. I learned of the new complexity code during 2024 Codequest. What is the difference between G2211 and linking to a noncompliance ICD-10 code?

    Answer: Applicable social determinants of health (SDoH) can be indicated by ICD-10 codes. When the situation significantly limits the physician’s ability to treat the patient, then they can be factored into E/M medical decision making, risk category. To arrive at the final E/M determination, two of three components (problems, data, and risk) must have the same level of complexity. Visit for E/M resources.

    For all ICD-10 selections, code to the highest level of specificity. As of Oct. 1, 2023, Z91.19- has three more specific definitions:

    • Z91.190 Patient’s noncompliance with other medical treatment and regimen due to financial hardship
    • Z91.198 Patient’s noncompliance with other medical treatment and regimen for other reason
    • Z91.199 Patient’s noncompliance with other medical treatment and regimen due to unspecified reason

    Beginning Jan. 1, 2024, G2211 is an add-on CPT code billable to Medicare in addition to the office/outpatient E/M visit. It is defined as:

    “Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care 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.”

    When billing G2211, chart documentation should support the physician’s management of all needed services, or ongoing care for a single serious condition or complex condition. The determining factor is the long-term relationship between the physician and the patient. It may not be appropriate to be billed every visit. Find current guidance on the Academy's G2211 fact sheet.

    Both the SDoH diagnoses and complexity add on code could be factored for a single patient when appropriate. However, they are not mutually exclusive and can be reported independently when meeting the unique definitions and coding guidelines.