Can Physicians Afford to Manage Chronic Ulcers With Multiple Comorbidities?

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Sometimes the best part of an educational program is the discussion and question and answer period that follows. This reimbursement strategy and education consultant/author recently experienced such a situation first-hand. After delivering a presentation about the top 5 ulcer management procedures that are causing failed audits, the physicians, podiatrists, and non-physician practitioners wanted to discuss real-life issues surrounding debridement. We turned off all recording devices so we could talk openly about their experiences. Although the discussion was lengthy and filled with examples, the participants’ basic issues were the same:

• New patients are presenting with chronic ulcers that have been present, and often mismanaged, for a long time. These patients also have multiple comorbidities that must be managed. Although they spend most of the encounter assessing the patient, ordering appropriate diagnostic tests, etc., they report a surgical debridement (which they might not have performed until they receive test results) because the allowable payment rate pays for their time.
• Once they know it is safe to debride the ulcers, they typically perform surgical debridement and correctly bill for the procedure.
• Once the ulcer is clean and starting to heal, they still must assess and clean the ulcer, manage the comorbidities, and coordinate the patient’s care. To receive adequate payment for all this work, they tend to report surgical debridement (which was not performed) because of its payment rate.

After listening to this discussion, it was clear why debridement audits often end in denials and repayments. This presenter/facilitator then asked if any of them thought about billing for evaluation and management (E/M), rather than debridement, which was not performed. Most said that documentation for E/M was too cumbersome. When asked if they had switched from reporting E/M based on the 1995 and 1997 guidelines to reporting based on medical decision making or time, most said “no” and the others said their electronic health record is still based on the old E/M guidelines. This presenter/facilitator encouraged them to do whatever it takes to implement reporting E/M based on medical decision making or time. Ulcer management professionals who have made the switch find that their assessment and coordination of care work usually result in higher levels of E/M payment.

After everyone understood the value of following the new E/M guidelines, which are now required, this presenter/facilitator asked if they had considered reporting an E/M code along with the new office and outpatient evaluation and management visit complexity add-on code G2211 that the Centers for Medicare & Medicaid Services (CMS) created. Their responses were, “there is no such code;” “that code is not covered by Medicare;” or “I do not know anything about G2211.” Therefore, this presenter/facilitator took the time to educate the participants that G2211 became effective January 1, 2024, when CMS changed it to “active status,” which made it separately payable under certain conditions.

At that point, the participants perked up and asked many questions about G2211. By the end of the discussion, they concluded that the modest allowable rate for G2211, in addition to the allowable rate for the appropriate E/M level, would provide a financially reasonable pathway for conducting thorough assessments of chronic wounds/ulcers, for managing comorbidities, and for coordinating care—without billing for debridement that was not needed/not performed. The group also concluded that they should immediately 1) refine their E/M documentation, and 2) allot more appointment time for these encounters.

Because G2211 appeared to be an unknown code to these ulcer management professionals, it may be unknown to the readers. Therefore, let us address the questions that were asked about the appropriate use of G2211.

Q:       When was G2211 created?

A:        This code was created in 2020, but its implementation was delayed for 3 years due to concerns about its monetary impact on the Medicare Physician Fee Schedule (MPFS).

Q:       Why was G2211 created?

A:        CMS wanted to provide professionals who are qualified to report E/M codes 99202–99215 a way to furnish services to patients on an ongoing basis that result in personalized care. The services should result in a comprehensive, longitudinal, and continuous relationship with the patient and involve delivery of team-based care that is accessible, coordinated with other practitioners and providers, and integrated with the broader health care landscape. The relationship between the physician and other qualified healthcare professionals (QHPs) and the patient is the most important determining factor for billing G2211. Following are the patient-physician/QHP relationships that qualify for G2211:

• If the physician/QHP is the continuing focal point for all the patient’s needed health care services, and/or
• If the physician/QHP furnishes ongoing medical care related to a patient’s single, serious condition, and/or
• If the physician/QHP furnishes ongoing medical care related to a patient’s complex condition

The main caveat about add-on code G2211 is that it must capture the inherent complexity of the visit that is derived from the longitudinal nature of the relationship between the physician/QHP and the patient.

Q:       What is the exact description of G2211?

A:       The code description is: “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.” The attached note to the description states: “Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established.”

Q:       What specialties may report G2211?

A:        CMS does not restrict G2211 to professionals based on their specialties.

Q:       Can G2211 be reported for both new and established patients?

A:        Yes, CMS allows G2211 to be reported for new and established patients if the required criteria are met and documented.

Q:       What is the exact process for reporting G2211?

A:        After the E/M visit, the physician/QHP determines the level of E/M performed based on either 1) medical decision making, or 2) time. Once the E/M level is determined, and if the visit met the code description and criteria for G2211, then the appropriate E/M level and G2211 may be reported on the same claim.

Q:       What are the documentation requirements for G2211?

A:        Although CMS does not require additional documentation for G2211, they and their medical reviewers will expect the visit documentation to include:

• Medical necessity for billing the outpatient or office E/M visit and for reporting G2211
• Diagnosis (diagnoses) that requires a longitudinal relationship between the patient and the physician/QHP
• The physician’s/QHP’s assessment and treatment plan
• The physician’s/QHP’s statement that identifies which of the G2211 criteria pertained to the visit and the extra work involved in becoming the focal point of the patient’s care or providing ongoing care for a serious or complex condition
• Time spent by the physician/QHP
• Other services provided and codes billed during the visit

Q:        If a procedure was performed and an E/M was reported with modifier -25 because a significant and separately identifiable service was provided to the same patient on the same day, can the physician/QHP also report G2211?

A:        No. CMS has made it perfectly clear that they will not pay for G2211 when reported on the same claim with an E/M code (99202–99205; 99211–99215) with modifier -25 for the same patient by the same physician/QHP.

Q:       Can a physician/QHP submit payment for G2211 without billing for a base E/M code?

A:        No, G2211 is an add-on code and can only be reported on a claim with an E/M code.

Q:       Is the patient responsible for coinsurance and deductible when G2211 is billed to Medicare?

A:        Yes, G2211 has a national average allowable rate for both facility and non-facility of $16.05 on the MPFS, and the patient is responsible for owed coinsurance and deductible.

Q:       Did CMS set a limit on the number of times that G2211 can be reported?

A:        No. However, remember that documentation must capture the inherent complexity of the visit that is derived from the longitudinal nature of the relationship between the physician/QHP and the patient.

Summary

Physicians, QHPs, and podiatrists should now understand that a debridement does not have to be reported, unless it was performed. In addition, they should be able to 1) conduct thorough ulcer assessments as the ulcer progresses/digresses, 2) manage comorbidities, and 3) coordinate care with the healthcare team member that are providing care for the patients. To implement better use of the E/M codes and the use of G2211, these professionals should 1) pay attention to all Medicare instructions and guidelines about the appropriate use of the E/M codes and G2211, 2) implement current E/M documentation requirements, and 3) instruct their billing staff about the appropriate coinsurance and deductible.
 
Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@gmail.com.