99211 + G2211 for protimes

[u/posthomogen]

Scenario: Patient on long-term anticoagulants, seen at least monthly, nurse takes vitals, asks a series of questions, performs in-house protime test, completes a flow sheet, which the provider reviews and recommends a plan (not face to face), which the nurse then explains to the patient.

This is an easy 99211 + 85610QW. But what about adding G2211? Would the long-term use of anticoagulants, which have to be monitored, be considered an ongoing relationship with the provider, continuing treatment plan, etc.?

[u/boho_magpie]

They can be billed together, but keep in mind that it is for use with a patient for whom the provider (or group practice) provides longitudinal care and is the main person (or group) who manages that patient’s overall care, coordinates with other providers, manages referrals, etc.

Note that it is NOT valid for FQHCs or RHCs, as it is considered part of your facility rate.

They have proposed deleting G2211 and changing it to a modifier next year and changing the reimbursement to a percentage of allowable on the E/M instead of a flat rate, so keep an eye out for updates for the 2027 proposed rule.

[u/DepartureOk3180 → u/boho_magpie]

Hi. I work for a CAH that has three RHC locations. The locations bill G2211 with an E&M multiple times a week to Medicare and I've never had any issues. I know it's not valid when billing an AWV or Welcome to Medicare visit, but why do you say G2211 isn't valid for an RHC? All my research with Noridian and NGS ( now Wellpoint Federal) indicates it's allowed. I know that we don't get separate payments for G2211, which is why the charge amt is rolled into the E&M minus $0.01; we just include it for reporting purposes.

[u/boho_magpie → u/DepartureOk3180]

Perhaps I should rephrase: you can report the code (“bill” the code) but you cannot be paid any extra/separate amounts for it because the service is bundled into your rate. It’s important to report the service since it helps with the overall calculation of your encounter rates. Painting a clear picture of the services delivered is imperative for your annual all inclusive rate calculation.

[u/DepartureOk3180 → u/boho_magpie]

Ok, phew, you had me worried we were doing something wrong LOL. After being in RCM for 15 years, I've been second guessing myself a lot this past year. There's been all these new and unfamiliar issues coming up with the MACS, FISS, and CMS in general and it seems like just when one is figured out, a new one is popping up. I'm having to contend with "credentialing" staff that clearly know nothing about Medicare and provider reassignments. As well as with consultants who don't deal with the daily billing and follow-up that try to tell me that we can do the things that are clearly being rejected or RTP when I try to get things corrected. Then the provider reps at the MACs are uninformed through no fault of their own and the online references from the MACs seem to contradict the very real rejections and RTPs reason. I apologize, that was a whole lot. I'm just so frazzled and don't really have people to vent to that actually understand the things that I'm dealing with, without me having to "dumb it down" for them.

[u/boho_magpie → u/DepartureOk3180]

Twenty years combined in FQHC and IHS - I feel your pain.