e visit billing codes

How to Code for Telehealth, Audio-Only, and Virtual-Digital Visits 

Learn how to accurately get paid for telemedicine services with medical codes for telehealth, audio-only, and virtual-digital visits.

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Coding for Telehealth Visits

Note:  These tables are informational, not advisory. The AAFP recommends that physicians verify each payer's policy and ask patients to verify their coverage ahead of appointments. 

How do I code a new or established patient telehealth office visit that uses audio-video communications technology?

* Elevance's  policies vary by state; contact your provider-relations representative.

Coding for Audio-only Visits

How do i code an audio-only visit for a new or established patient .

CPT Codes: 99441-99443 

Audio-only scenario notes 

Medicare requires audio-video for most office visit evaluation and management (E/M) services (CPT codes 99202-99215) telehealth services. Audio-only encounters are allowed for certain services. Eligible services may be found on the Medicare Telehealth Services list. Medicare allows audio-only telehealth services for office visit E/M services (CPT codes 99202-99215) for the treatment of mental health conditions.   

UHC states they will consider payment for eligible audio-only services listed in Appendix P of the CPT book. Eligible services must be reported using either POS 02 or 10 and include the -93 modifier. CPT codes billed with modifier -93 that are not in Appendix P will not be considered for payment.   

Private payers vary on covered telehealth services. Check with your provider relations representatives for each payer’s telehealth policy and covered telehealth services. 

CMS will cover telephone evaluation and management (E/M) services (CPT codes 99441-99443) through the end of calendar year 2023. Other services that may be provided via audio-only are available on the Medicare Telehealth List. 

Telephone E/M services are provided to a patient, parent, or guardian and do not originate from a related E/M service within the previous seven days and do not lead to an E/M service or procedure within the next 24 hours or soonest available appointment. 

The following codes may be used by physicians or other qualified health professionals who may report E/M services: 

• 99441: telephone E/M service; 5-10 minutes of medical discussion 
• 99442: telephone E/M service; 11-20 minutes of medical discussion 
• 99443: telephone E/M service, 21-30 minutes of medical discussion 

Telephone E/M services should not be reported when the time spent on the telephone is captured in other services reported, such as: 

• if CPT codes 99421-99423 have been reported by the same physician in the previous seven days for the same problem, 
• when CPT codes 99339-99340 and 99374-99380 are used for the same call, 
• during the same month with CPT codes 99487 and 99489, and 
• when performed during the same service period at CPT codes 99495-99496. 
• Self-funded plans can develop their own policies and may opt out of some cost-sharing waivers. Similarly, Medicaid policies are established at the state-level. The AAFP recommends reaching out to your provider relations representatives or Medicare Administrative Contractors (MACs) to verify policies.  

Coding for Virtual-Digital Visits 

How do i code an e-visit (cpt 99421-99423) for an established patient .

CPT Codes: 99421-99423 

How do I code a virtual check-in (HCPCS codes G2012 and G2010) for an established patient? 

HCPCS Codes: G2012, G2252, G2010 

Virtual/Digital Scenario Notes 

• Patient consent is required and may be obtained either before or at the time of service. 
• Virtual check-ins and e-visits must technically be initiated by a patient; however, physicians and other providers may need to educate beneficiaries on the availability of the service prior to patient initiation. 
• There are no POS or modifier requirements for virtual check-ins or e-visits. Use the POS used for typical services. 

Virtual Check-in (HCPCS Code G2012, G2252) 

• These are brief conversations with a physician or other clinician to determine if an in-person visit is necessary. 
• The communication cannot be related to a medical visit within the previous seven days and cannot lead to medical visit within the next 24 hours (or soonest appointment available). 
• Physician or other clinician may respond to patient by telephone, audio/video, secure text messaging, email, or patient portal. 
• HCPCS code G2010 can be used when a captured video or image (store and forward) is sent to the physician. The physician must follow up with the patient within 24 business hours. The consultation must not originate from an evaluation and management (E/M) service provided within the previous seven days or lead to an E/M service within the next 24 hours (or soonest available appointment). 

E-Visits (online digital evaluation and management services) 

• These are non-face-to-face, patient-initiated communications with the physician through an online patient portal. The communications can occur over a seven-day period, and the exchange must be stored permanently. 
• Cumulative time includes review of the initial inquiry, review of patient records pertinent to the assessment of the patient’s problem, personal interaction with clinical staff focused on the patient’s problem, development of management plans (including generation of prescriptions or ordering of tests), and subsequent communication with the patient. Communication can occur through online, telephone, email, or other digitally supported communication 

Physicians and other clinicians who may independently bill Medicare for E/M services can use the following codes:

• 99421: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes 
• 99422: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes 
• 99423: Online digital evaluation and management service, for a patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes 

E-visits should not be billed on the same day the physician reports an office visit E/M service (CPT codes 99202-99205 and 99211-99215) for the same patient. Additionally, e-visits should not be billed when using the following codes for the same communication: 

• 99339-99340 
• 99374-99380 
• 99487 and 99489 
• 99495-99466 

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Best Guide to E-Visit Documentation, Coding, and Billing

Categories: Coding , CPT Codes , Medical Billing

Tags: billing code , coding , cpt code tips , e visits in healthcare , medical billing

The American Academy of Family Physicians (AAFP) encourages safe, secure online interactions between physicians and patients, such as electronic visits or “virtual e-visits.” In non-emergency situations, e-visits can substitute for office visits with primary care providers. It is a fast and easy online procedure for patients to receive a diagnosis and treatment plan.

This article will give you the best guide to e-visit documentation, coding, and billing.

What Should Providers Know About E-visits? 

An encounter must meet the following criteria to be considered an e-visit:

• The practice must have a well-established relationship with its patients.
• E-visits require patient consent and a communication request.
• The patient must initiate non-face-to-face electronic communication. For example, patient portal systems.
• Patients must not have seen an office visit to a physician or therapist for the same clinical concern in the past seven days.
• It is only possible to report e-visits every seven days.
• An e-visit is not the same as typical therapy sessions.

For e-visits, the following documentation requirements are needed:

• The main complaint with all evaluation and management services (E/M).
• The specifics of treatments, assessment of diagnoses or symptoms, evaluation, and conversation.
• An official patient consent record is backed up by a signature and captured in the clinical note. Moreover, e-visit software platforms accept scanned copies of signed consents. Some systems allow electronic signatures.
• The total time recorded over the seven days supporting the billable service.

List of Current Procedural Terminology (CPT) Codes That Require Providers to Follow Policies Set by Payers

The codes for online digital evaluation services (e-visits) used by doctors are complex. Below are the codes used:

Medicare uses the following HCPCS codes and descriptors for qualified non-physician professionals for its online digital evaluation service (e-visit):

Private payers and workers’ compensation are using the following online digital evaluation service (e-visit) CPT codes and descriptors:

Do’s and Don’ts in Billing E-Visits

When the following conditions are met, you can bill an e-visit:

• The provider establishes a relationship with the patient.
• Response time by the provider is longer than five minutes.
• A provider responds through the patient portal to a message initiated by the patient.
• A visit meets the 2021 E/M guidelines. 
• It has been seven days since the clinician last saw the patient.
• There is no global period for the same or similar condition for the patient.
• In this case, the provider is making a clinical decision that would normally be performed in the office (e.g., medication dose adjustment, ordering a test, or prescribing a new medication).
• A patient has consented to the e-visit and understands that he may be billed.
• For online digital E/M services, the service period includes all related work done within seven days by the reporting individual and other registered healthcare providers (RHPs) in the same group practice.
• The 7-day period begins when the reporting provider reviews the patient’s inquiry personally for the first time.
• A new/unrelated problem from the patient arises within seven days of the previous E/M visit for a different issue.

Do not bill an E-visit in the following situations:

• During the 7-day period, the provider may bill for other separately reported services (such as care management, INR monitoring, remote monitoring, etc.)
• The same or similar condition was billed to the patient for an e-visit within the past 7 days. 
• The patient inquires about a surgical procedure that happens during the surgery’s postoperative period (global).
• Providers are simply disseminating results, processing medication requests, or scheduling appointments (for billing, E/M services must be performed).
• A separate face-to-face E/M service (either in person or via telehealth) happens (included in the E/M) during the 7-day period of the e-visit.
• Besides clinical staff time, only provider time can be included.

The AAFP published an algorithm in response to the growing number of virtual visits. It was developed by James Dom Dera, MD, FAAFP, to determine which code should be used for virtual services.

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June 9, 2024

CPT® Codes (99421-99423) – and Payment for – Online Digital Evaluation and Management (E/M) Services

Or, as I call them: message, manage, message.

There are CPT codes for online digital E/M services.

• CPT developed a set of  CPT ® codes for use by physicians, physician assistants and advanced practice nurse practitioners performing brief, online E/M services via a secure platform
• There are also CPT® codes for use by clinicians who do not have E/M within their scope of practice codes 98970—98792
• CMS is requiring verbal consent for communication-based technology services (CBTS)
• This verbal consent is required annually, and encompasses all CBTS, not a consent for each service service or consent for each provision of the service
• These are not considered telehealth services, so do not use POS 02 and modifier 95. Why? they are not on CMS’s list of covered telehealth services, and do not use real-time, interactive audio-visual communication
• Everyday Coding Q&A – Licensed professional counselors and use of 99421–99423

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Including updates on CPT ® and CMS coding changes for 2024

Watch the short video below to review the guidelines for coding online digital E/M services. The video includes a review of CPT codes for online digital E/M services, and HCPCS codes G2010, G2012, G2250, G2251, G2252. Read more about those HCPCS codes in the article linked at the bottom of this post.

CPT® codes for online digital E/M

99421 Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes

99422             11—20 minutes

99423             21 or more minutes

These codes are for use when E/M services are performed, of a type that would be done face-to-face, through a HIPAA compliant secure platform. They are not to be used for non-evaluative functions, such as test results, appointment scheduling  or other communication that doesn’t include evaluation and management. These are for established patients and require a patient-initiated communication. They may not be used for work done by clinical staff or for clinicians who do not have E/M services in their scope of practice.  They are “messaging” codes, not telephone, video or in person services.

Report these services once during a 7-day period, for the cumulative time. According to CPT ® ,

“The seven-day period begins with the physician’s or other qualified health care professional’s (QHP) initial, personal review of the patient-generated inquiry. Physician’s or other QHP’s cumulative service time includes review of the initial inquiry, review of patient records or data pertinent to assessment of the patient’s problem, personal physician or other QHP interaction with clinical staff focused on the patient’s problem, development of management plans, including physician  or other QHP generation of prescriptions or ordering of tests, and subsequent communication with the patient through online, telephone, email, or other digitally supported communication, which does not otherwise represent separately reported E/M service.” [1]

They begin with the patient-initiated portal message. The practitioner reviews the communication and the medical record and manages the problem. It may be a prescription, test, or advice.  Often, there is back and forth messaging, and all of the practitioner time in the 7 day period counts.

If the patient is seen in person or via telehealth within the 7 day, codes 99421-99423 are not reported. If the messaging relates to an E/M service that occurred within the last 7 days and is related to the problem for which the patient was seen, it is not reported. However, if a patient generates a message regarding a new problem during the 7 days after an E/M visit, and that doesn’t result in an E/M service, these codes may be used.

These are time based codes, with time ranges in the code descriptions. A practitioner may never use the same time period to meet requirements for two different services. They may not be reported on the same day as an E/M service. Look in your CPT book. There is a long list of “do not report” codes.

Other requirements:

• Verbal consent is required by CMS.
• The patient initiates the service with an inquiry through the portal.
• The service is documented in the medical record.
• If the patient had an E/M service within the last seven days, these codes may not be used for communication related to that problem.
• If the inquiry is about a new problem (from the problem addressed at the E/M service in the past 7 days), these codes may be billed.
• If within seven days of the initiation of the online service a face-to-face E/M service occurs, then the time of the online service or decision-making complexity may be used to select the E/M service, but this service may not be billed.
• These are for established patients, per CPT ® .
• This may not be billed by surgeons during the global period.
• The digital service must be provided via a HIPAA compliant platform, such as an electronic health record portal, secure email or other digital applications.

Additionally:

• These services may only be reported once in a 7-day period.
• Clinical staff time may not be included.
• Don’t double count time with any other separately reported services, such as care management, INR monitoring, remote monitoring. (CPT ® book has a list of codes)

Online services provided by clinicians who may not bill E/M services

CPT © codes for clinicians who do not have E/M services in their scope of practice, 98970—98972.  There is an editorial notation after codes 99421, discussed above, that says:

“For online digital E/M services provided by a qualified nonphysician health care professional who may not report the physician or other qualified health care professional E/M services (eg, speech-language pathologists, physical therapists, occupational therapists, social workers, dietitians), see 98970, 98971, 98972).” [2]

CMS has assigned these as active codes.

98970 Qualified nonphysician health care professional online digital assessment and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

98971     11-20 minutes

98972    21 minutes or more

Question: Can a licensed professional counselor use codes 99421–99423 for digital management of a client initiated issue, such as a client-based email inquiry related to their therapy problem? Answer : No.

These codes appear in the Evaluation and Management section of the CPT® book, and are for use by physicians and other qualified health care professionals. The definition is “online digital evaluation and management service.” Licensed professional counselors do not have E/M services in their scope of practice. If a code is defined as an E/M service, it may only be performed by someone who has E/M in their scope; that is, someone who can perform an office visit or initial hospital service.

There are equivalent codes in the medicine section of the book. In the CPT® 2023 Professional Edition, these start on page 846. The heading is “Qualified Nonphysician Health Care Professional Online Digital Assessment and Management Service.” These codes do not use the words evaluation and management service.  They are 98970, 98971, 98972. Be sure to read the entire section at the start of the codes for the very specific CPT® instructions on their use.

It is confusing, because sometimes both CMS and CPT® use “physician” to include advanced practice nurses and physician assistants.

Virtual Communication: HCPCS Codes G2010, G2012, G2250, G2251, G2252

[1] CPT Professional Edition, 2024. AMA, Chicago, p. 39.

[2] CPT Professional Edition, AMA, Chicago 2024, page 39.

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Last revised April 1, 2024 - Betsy Nicoletti Tags: telehealth

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Meet the New CPT Codes to Report e-Visits in 2020

by Natalie Tornese | Published on Feb 10, 2020 | Medical Coding

Digital E/M services allow US health systems to care for patients remotely. Several factors are fuelling the growth of remote patient monitoring and telemedicine, such as the aging population, patient demand, looming provider shortage, increase in chronic conditions, and policies to promote reimbursement for e-visits. Recognizing the expanding role of telemedicine in the U.S., the American Medical Association introduced six new e-visit CPT codes, which came into effect from Jan. 1, 2020. Providers can use physician billing services to accurately report these new codes for online digital evaluation services and get optimal reimbursement.

Six new CPT Codes for e-Visits

The 2020 Medicare Physician Fee Schedule (MPFS) describes e-Visits as non-face-to-face “patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office.” The six new codes for e-Visits are:

• 99421 , 99422 , and 99423 to report patient-initiated digital communication provided by a physician or other qualified healthcare professional
• 98970 , 98971 , and 98972 for digital communications with a non-physician healthcare professionals

“The new CPT codes will promote the integration of these home-based services that can be a significant part of a digital solution for expanding access to health care, preventing and managing chronic disease, and overcoming geographic and socioeconomic barriers to care,” said AMA President Patrice A. Harris, MD, MA.

Two New Codes for Self-measured Blood Pressure Monitoring (SMBP)

In addition to the above six codes, there are two new codes for SMBP in 2020.

High blood pressure or hypertension is a common problem that increases risk of heart attack and stroke risk. The goal of treatment is to bring the blood pressure level down to a healthy range (130/80 millimeters of mercury [mm Hg] or lower). SMBP can support this goal.

SMBP involves a patient’s regular use of personal blood pressure monitoring devices to assess and record blood pressure across different points in time outside of a clinical, community, or public setting, typically at home (www.cdc.gov). Monitoring blood pressure at home can help people newly diagnosed with high blood pressure or those struggling to reach their target. Harvard Health reported on research which showed that a period of home blood pressure monitoring – one week per month – was sufficient to guide people to better blood pressure control.

According to AMA Vice President of Health Outcomes Michael Rakotz, MD, SMBP provides clinically useful information to help physicians:

• more accurately diagnose and determine the need for treatment in people suspected of having uncontrolled high blood pressure based on routine office BP measurements
• compared to BPs obtained during a single office visit, SMBP provides more BPs over a longer period of time, which represents a more accurate picture of a patient’s BP
• Out-of-office measurements can better predict future cardiovascular risk than measurements taken in the office

In 2020, physician practices that educate patients to perform home blood-pressure monitoring can submit claims using two CPT codes associated with clinical services:

• 99473 Self-measured blood pressure using a device validated for clinical accuracy; patient education/training and device calibration
• 99474 Separate self-measurements of two readings one minute apart, twice daily over a 30-day period (minimum of 12 readings), collection of data reported by the patient and/or caregiver to the physician or other qualified health care professional, with report of average systolic and diastolic pressures and subsequent communication of a treatment plan to the patient

These codes will enable physicians to better diagnose and manage hypertension as well as help patients to play an active role in their care while at home.

Reporting 99421, 99422 and 99423 – Points to Note

• Codes 99421-99423 are for physicians and other qualified healthcare professionals (QHP)
• These codes can be used to report non-face-to-face patient initiated digital communications that require a clinical decision
• CPT code selection should be based on the time involved
• Communication between the patient and provider should be performed through HIPAA-compliant platforms (electronic health record portal or secure email)
• These codes should not be used for non evaluative electronic communication of test results

There are also guidelines on when not to bill online services when the patient is provided another service around the same time as online communication:

• Digital E/M followed by other E/M : If the patient initiates an online E/M service and then presents for a separately reported E/M within seven days, the online E/M work should be included in the separately reported E/M.
• E/M followed by online service : If the patient presents for an E/M and then initiates an online inquiry for the same problem or a related one within seven days, the online service should not be reported.
• Online E/M during post-op period : During the postoperative period, online inquiries related to a surgery should not be reported separately.

Hospitals and health systems are looking to expand care to the home or other non-traditional settings and work with patients and other care providers to improve outcomes and reduce costs. Providers who implement digital health care services can rely on medical billing outsourcing services to report the new codes correctly and get paid.

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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How to correctly document and bill for patient e-visits

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2024 Coding Guide: Part 2 - Medicare Advantage

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Office/Outpatient E/M Codes

2021 e/m office/outpatient visit cpt codes.

The tables below highlight the changes to the office/outpatient E/M code descriptors effective in 2021.

More details about these office/outpatient E/M changes can be found at CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes.

All specific references to CPT codes and descriptions are © 2023 American Medical Association. All rights reserved. CPT and CodeManager are registered trademarks of the American Medical Association.

Download the Office E/M Coding Changes Guide (PDF)

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Best Practices

The Ins and Outs of G2211: A Billing Code to Capture the Work You Are Already Doing

Caroline E. Sloan, MD, MPH; Quratulain Syed, MD; Celeste Newby, MD, PHD

Introduction

Physician reimbursement has historically placed higher value on procedural services and lower value on outpatient office evaluation and management (E/M) services, such as those provided by primary care providers (PCP). 1 Relaxation of documentation requirements for E/M visits in 2021 led to increased payments for PCPs, but only a 2% decline in the reimbursement gap between PCPs and proceduralists. 2 With the release and implementation of the G2211 code in January 2024, the Centers for Medicare and Medicaid (CMS) provided an additional mechanism for primary care providers and other physicians to receive payment for the work they do every day. 3,4

G2211 is an add-on code for outpatient office E/M visits that reimburses clinicians for additional work associated with providing comprehensive, longitudinal, and continuous care to patients with complex condition(s) or a single serious condition. It accounts for aspects of care that are not captured by other billing codes, including developing effective and trusting relationships over time, acting as the “continuing focal point for all needed services,” and understanding how a patient’s medical and/or social history may affect their health today. 3,4 CMS estimates that the G2211 code will be used frequently by non-procedural clinicians and much less by surgeons and proceduralists. 3,4

As this code is still in the early stages of implementation, questions about its usage are common. This article describes appropriate usage of the G2211 code and provides clinical examples that may arise in a PCP’s daily practice.

What Is the Payment for G2211 and What Insurance Covers It?

The 2024 national Medicare allowable cost for G2211 is $16.04. 5 Only Medicare Part B is required to cover G2211. As of March 1, 2024, Cigna, Humana, and United Healthcare Medicare Advantage plans, as well as Humana and United Healthcare commercial plans, also cover the G2211 code. 5 Many health systems encourage clinicians to bill this code when appropriate to support its adoption by additional payers.

When Should I Use G2211?

The G2211 code can be used by physicians and advance practice providers (e.g., nurse practitioners and physician assistants) if the following criteria are met: 3,4

• The billing clinician works within a fee-for-service payment model;
• The encounter is an outpatient office E/M visit;
• The clinician is not performing a procedure that would entail adding on a 25-Modifier; and
• The clinician has established or intends to establish a longitudinal relationship with the patient (“continuing focal point for all needed health care services”) and provides ongoing care of one or more complex condition(s) or a single serious condition.

CMS does not stipulate any restrictions tied to length of clinical encounters, acknowledging that while expert PCPs are able to manage multiple complex problems in a short time, the cognitive load required to do so is high.

How Should I Use G2211?

Clinicians should continue using the same Current Procedural Terminology codes for outpatient office E/M visits. They can then capture G2211 as an add-on code when appropriate. There are no additional documentation requirements beyond describing the care provided for the patient’s chronic conditions and the development or implementation of a care plan. Note that G2211 is meant to specifically reimburse clinicians for their professional work during the clinical encounter, rather than any care management endeavors conducted outside of the encounter, which are billed separately.

When Should I Not Use G2211?

The code should not be used in following situations: 3,4

• The clinician uses a 25-Modifier on the same day as the clinic visit; the 25-Modifier is used to bill for minor office-based procedures such as suture removals and joint injections;
• Acute visits that do not involve management of chronic issues (e.g., specialty consultations, urgent care visits);
• Management of conditions that have a limited course (< 3 months) if the clinician does not plan to treat the patient longitudinally;
• The billing clinician works in a capitated payment model; and
• Medicare Annual Wellness Visits.

CMS chose not to allow use of the G2211 code in conjunction with the 25-Modifier to ensure that the G2211 code would be used primarily by clinicians delivering longitudinal care.3 However, one might envision scenarios in which coding for both G2211 and the 25-Modifier could be appropriate. For example, a PCP might engage in a discussion about diet and lifestyle while simultaneously preparing for and conducting a knee steroid injection. Physicians should use their experiences with similar scenarios to advocate for future adjustments in implementation of the G2211 code.

Clinical Examples

A PCP sees her established patient with hypertension for a walk-in visit, for evaluation of a sore throat. The PCP recommends over-the-counter remedies, counseling to avoid medications that raise blood pressure.

Yes, use G2211 for this condition that has a limited course because the PCP considered the patient’s hypertension when providing recommendations, and hypertension is a chronic condition the PCP manages. The PCP should use the sore throat and hypertension diagnosis codes for this visit.

A patient presents to their PCP for their Medicare Annual Wellness visit. The clinician and patient discuss management of the patient’s diabetes and hypertension.

No, here the Annual Wellness Visit code acts as a 25-Modifier, so the G2211 code is not allowed.

A patient presents to establish care with a new PCP. The patient has hypertension and diabetes.

Yes, the patient has chronic issues that the PCP plans to manage longitudinally.

An endocrinologist sees an established patient for uncontrolled diabetes. She adjusts the patient’s short-acting insulin dose. She then calls the patient’s caregiver to relay the plan and schedules a four-week follow-up visit.

Yes, G2211 is not designed to be specialty-specific; if the code requirements are met, clinicians of any specialty can use it.

A PCP sees an established patient with hypertension and gout who has a knee effusion. He performs an arthrocentesis, adjusts the patient’s antihypertensives, and schedules a follow-up visit.

No, a procedure was performed, and a 25-Modifier will be used; a clinician cannot code for G2211 and the 25-Modifier on the same day.

A resident sees an established patient in follow-up for their diabetes, hypertension, and congestive heart failure. The attending precepts the resident and sees the patient.

Yes, use G2211 as an attending physician precepting in resident clinic; if the attending does not see the patient, it is still ok for them to use G2211 as long as they have permission to use the primary care exception.

A nurse practitioner sees an established patient in follow-up for their diabetes, hypertension, and congestive heart failure.

Yes, nurse practitioners and physician assistants can use G2211 when seeing patients independently.

A PCP sees an established patient in a telehealth visit, during which they discuss the patient’s mental health. The physician recommends starting a new antidepressant.

Yes, use G2211 during telehealth visits when appropriate.

A PCP sees a patient with diabetes who is established with a different clinician in their practice. That clinician is out sick today. The PCP and patient discuss a new diabetic foot ulcer and agree on changes to the patient’s diabetes regimen.

Yes, if the patient has developed a longitudinal relationship with their PCP’s “care team,” then using G2211 is appropriate.

While billing and coding can be cumbersome, G2211 is evidence that CMS is making major efforts to address PCPs’ reimbursement concerns. G2211 is not perfect, but it is a major step towards improving reimbursement to clinicians in the non-procedural specialties that have historically been undervalued. 1,2 In particular, this new code could help SGIM members in primary care and non-procedural specialists offset the financial impact of recent Medicare reimbursement cuts, without significantly increasing their administrative burden.

• Kumetz EA, Goodson JD. The undervaluation of evaluation and management professional services: the lasting impact of current procedural terminology code deficiencies on physician payment. Chest. 2013;144(3):740-745.
• Neprash HT, Golberstein E, Ganguli I, et al. Association of evaluation and management payment policy changes with Medicare payment to physicians by specialty. JAMA. 2023;329(8):662-669.
• Centers for Medicare & Medicaid Services. Medicare and Medicaid Programs; CY 2024 Payment policies under the Physician Fee Schedule and other changes to Part B payment and coverage policies; Medicare Shared Savings Program requirements; Medicare Advantage; Medicare and Medicaid provider and supplier enrollment policies; and Basic Health Program. https://www.federalregister.gov/documents/2023/11/16/2023-24184/medicare-and-medicaid-programs-cy-2024-payment-policies-under-the-physician-fee-schedule-and-other . Published online November 6, 2023. Accessed May 15, 2024.
• Calendar Year (CY) 2024 Medicare Physician Fee Schedule final rule. CMS.gov. https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule . Published November 2, 2023. Accessed May 15, 2024.
• G2211 Add-on code: What it is and how to use it. Amer Assn Family Physicians. https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/evaluation-management/G2211-what-it-is-and-how-to-use-it.html . Accessed May 15, 2024.

SGIM Forum: June 2024

Clinical Practice, SGIM

Author Descriptions

Dr. Syed ( [email protected] ) is a geriatrician at Joseph Maxwell Cleland VA Medical Center in Atlanta, GA. Dr. Newby ( [email protected] ) is an assistant clinical professor of medicine at Tulane University School of Medicine. Dr. Sloan ( [email protected] ) is an assistant professor of medicine at Duke University School of Medicine.

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Place of Service Codes

Place of Service Codes are two-digit codes placed on health care professional claims to indicate the setting in which a service was provided. The Centers for Medicare & Medicaid Services (CMS) maintain POS codes used throughout the health care industry.

This code set is required for use in the implementation guide adopted as the national standard for electronic transmission of professional health care claims under the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA directed the Secretary of HHS to adopt national standards for electronic transactions. These standard transactions require all health plans and providers to use standard code sets to populate data elements in each transaction. The Transaction and Code Set Rule adopted the ASC X12N-837 Health Care Claim: Professional, volumes 1 and 2, version 4010, as the standard for electronic submission of professional claims. This standard names the POS code set currently maintained by CMS as the code set to be used for describing sites of service in such claims. POS information is often needed to determine the acceptability of direct billing of Medicare, Medicaid and private insurance services provided by a given provider.

Chapter 26 - Completing and Processing Form CMS-1500 Data Set (PDF)

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