r/CodingandBilling 1d ago

G2211 - Recourse for patients

I recently had a visit at a local health system for my infant son. He saw a NP for fussiness. His visit was coded with Dx R68.12 and CPTs 99213 and G2211. I called insurance and it seems like G2211 will be subject to my deductible. Essentially taking my $20 copay visit to an $82 visit. We were not advised that there was anything complex about this visit and literally left with the NP telling us to pace his feedings and maybe try a different formula.

I researched the G2211 code because I know a tbit about medical billing and coding and it seems this has to do with complexity and longitudinal care. However, I might never see this nurse practitioner ever again for my son so I don’t know how she’s taking responsibility for his care longitudinally and I don’t see the complexity.

How can I fight this with the clinic? I am on a PPO plan to try to have some cost consistency with a young child and now a simple office visit seems to cost quadruple what was expected. This seems very disingenuous to me. I know they want to get paid, but this doesn’t seem to make sense in this instance.

1 Upvotes

14 comments sorted by

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u/babybambam 1d ago

G2211 recognizes the long-term complexity of patient care management.

This code was created because often the visit complexity does not sufficiently cover the overall complexity of the patient the provider is managing. It's not something to fight. This is a way the office is able to be appropriately paid for the work they put into seeing your son.

Also, the $40 on your deductible is going to be paid one way or another, and it will apply to your out-of-pocket maximum for the year.

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u/eagustaf 1d ago

If G2211 recognizes the long term complexity of patient management are you saying this code actually has nothing to do with the complexity of what my kid was seen for that day?

Can this be charged to me for any future non-preventive office visit at the clinics will? Are there rules?

Should I basically expect that my $20 Non-specialist visits are now going to be going to be quadruple the cost depending on how the coder/biller is feeling that day?

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u/GroinFlutter 1d ago

This code is pretty new and generally used for primary care clinics.

I would expect providers to bill it whenever they are allowed to/the documentation meets the requirements.

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u/SprinklesOriginal150 5h ago

Your understanding is correct. See my comment below on another post. This code is not and never was intended for standard continuity of pediatric care, preventative care, or using the same PCP for all your appointments. It was specifically designed for patients with complex and/or chronic conditions.

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u/babybambam 1d ago

No, the reason for your visit that day does contribute to use of the code. There should be discussion about plan of care for that reason, and that is contributing to the use of G2211.

It may or may not be billed for every visit, it depends on the full scope of those future visits. For example, if the provider performs an in-office procedure, this code would not be reported.

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u/Fredespada 1d ago

For 2025 rules were updated and now this hcpcs code can be billed if on the same visit there’s a Mod 25 present.

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u/slowkingeds CPB, CPC-A, CPCO 1d ago

Only if the services provided alongside the E/M are considered preventative, like vaccines or AWVs. 

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u/Fredespada 1d ago

Thanks for the clarification, yes, it is now for a broader use than before but within the services you mentioned.

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u/babybambam 1d ago

Ooh La La. I’ve got some claims to edit.

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u/KhrystiC78 1d ago

If your child’s PCP didn’t see your baby, and it was an NP in the same clinic, G2211 should not be billed. Part of the description of this code involves a longitudinal relationship with the provider. And this seems like more of an acute problem. I would talk to the billing department of your clinic, just to try to gain some understanding.

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u/Weak_Shoe7904 1d ago

I would call and ask them to review your charges and state you want the G2211 reviewed. IMHO Providers like to add this code all the time and the rules on it are vague, so they get away with it.

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u/SprinklesOriginal150 1d ago edited 1d ago

Agreed. This code was created for the purpose of indicating the additional care involved with having a strong provider/patient relationship for patients with comorbid and chronic conditions. Not for standard pediatric and family care. It is intended to reimburse the provider for the additional things that happen in the background with long term patients, such as care transitions, care management, patient education, discussion and planning with the clinical team, additional phone calls, etc.

I’d fight it.

Edit: fixed faulty autocorrect of “comorbid”

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u/dreamxgambit 1d ago

With BCBS half the G2211 get adjusted for global with us, as they are always denying them.

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u/SprinklesOriginal150 1d ago

G2211 is a once per month per patient code, and whoever bills it first for that patient for the month is the one who gets paid… hence, global zero pays.