Coding When Caring for a Complex Condition

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Podiatric physicians may have multiple pertinent questions when coding for a complex condition. Today I am sharing an example of a HCPCS code that may apply in these cases, as well as when and when not to use it, how to use this add-on code, and the importance of documentation.
 
HCPCS G2211—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.¹

When To Use

Submit this code when performing an office or other outpatient evaluation and management (E&M) service and that E&M is:

• Part of providing all needed health care services for that patient
  and/or
• Part of ongoing care related to a patient’s single, serious condition
  and/or
• Part of ongoing care related to a patient’s complex condition

One may submit G2211 for either a new or established patient.

Using This Add-on Code

When submitted, list G2211 on the claim form in addition to the appropriate office or other outpatient evaluation and management CPT^® code. Never submit G2211 alone. When performing an E&M that meets the above criteria, select the E&M level using either medical decision making or total time. After that process is complete and after determining the level, one may add G2211 to the claim form if the above criteria have been met.

When Not To Use

One exception to all of the above is one may not add G2211 to an E&M service that has a 25 Modifier appended to it.

Documentation

If one adds G2211 based on 1 or more of the 3 criteria listed above, document that criteria. For example, if all of the other documentation supports the claim, the following sentence may be included:

“This E&M of this chronic ulcer was part of the ongoing care I am providing related to this complex condition.”
 
An example could be a patient who suffered a dislocated ankle with related nerve damage and subsequent numbness in their lower extremity. The note describes that electromyography demonstrated areas of absent nerve function. The note also describes the discussion of treatment options, and that the physician made the decision to attempt therapy and hope that nerve function returns but if it doesn’t surgical repair is an option. An example of added documentation that may support submission of G2211 is:
 
This patient’s injury and subsequent pathology of the lower extremity is a complex condition. This complexity is created by the complications of the injury, the degree to which it is impacting life, and the risks involved with some of the options being considered, particularly the surgical options. The medical care services provided by me today carry with them complexity that is inherent to today’s evaluation and management of this complex condition. Furthermore, the care provided today represents longitudinal care as this service was part of ongoing care for this problem that requires a “consistent and coherent approach to the management of a health condition that is responsive to a patient's changing needs.” Therefore, HCPCS code G2211 was submitted with this encounter.
 
Dr. Lehrman is a Board Certified Podiatrist, Certified Professional Coder, and Certified Professional Medical Auditor. He operates Lehrman Consulting, LLC which provides guidance regarding coding, compliance and documentation. 
 
Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure accuracy. However, HMP and the author do not represent, guarantee, or warranty that coding, coverage, and payment information is error-free and/or that payment will be received.
 
Reference
1. Centers for Medicare and Medicaid Services. List of CPT/HCPCS Codes. Accessed July 25, 2024.