Robert A. Dowling, MD1; Mark Painter, MBS, CPMA2; Evan Goldfischer, MD3
1Dowling Medical Director Services, Fort Worth, Texas
2PRS Managed Services, LLC, Broomfield, Colorado
3Premier Medical Group of the Hudson Valley, Poughkeepsie, New York
KEYWORDS:
Clinical coding; ambulatory care facilities; urologic diseases; ambulatory care; practice patterns, physicians’
Abstract
Background: In January 2024 the Centers for Medicare & Medicaid Services began reimbursement for a Healthcare Common Procedure Coding System add-on complexity code (G2211) applied to eligible evaluation and management visits. This study examines the use of and reimbursement for this code in urology practices in the first 6 months of 2024.
Methods: Study data were sourced from the adjudicated claims of 2305 clinicians in 40 independent (privately owned) practices across the United States from January 1 to June 30, 2024. Use of the complexity code was identified among all encounters and in just those encounters deemed eligible according to published regulations. Utilization rates, reimbursement rates, and reimbursement amounts were calculated across patient and practice characteristics.
Results: A total of 1 664 858 patients and 1 938 108 encounters with an evaluation and management service were included in the analysis. The complexity code was used in 31% of such encounters and 38% of encounters after excluding visits involving modifier 25. Utilization in potentially eligible encounters for prostate cancer (46%), bladder cancer (53%), and other chronic urologic conditions was lower than expected. Medicare reimbursed more often (96% of claims) and with a higher average payment ($16) for the add-on code than commercial payers did (69.3% of claims, $13).
Conclusions: The G2211 add-on complexity code appears to have been underused in urology practices since its implementation in January 2024. The urology practice is the focal point of care for patients with many qualifying conditions, and this study identified a need to raise awareness of the appropriate use of the new complexity code.
The Centers for Medicare & Medicaid Services (CMS) estimate that approximately 40% of all allowed charges are for evaluation and management (E&M) visits. Historically, E&M visits have been paid according to levels determined by complex rules and documentation requirements, with wide variation in volume and coding levels across specialties.1 CMS sought to address this issue by simplifying coding levels and documentation requirements and by creating (beginning in 2021) an add-on code to indicate higher visit complexity when the clinician serves as the focal point for the patient’s overall care or chronic condition. The official description of Healthcare Common Procedure Coding System (HCPCS) add-on code G2211 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. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established).2
CMS has indicated that this code would be appropriate for visits with primary care physicians managing a patient’s overall care and for visits with clinicians who are the focal point for ongoing care related to a patient’s single serious condition or a complex condition. It is the longitudinal relationship between the patient and the clinician that determines appropriate use of this code.3 Urologists often serve this focal role when managing several medical conditions, including those of patients with prostate cancer and bladder cancer. Many of these E&M services would therefore presumably qualify for the complexity code as currently defined. Although payment by CMS for HCPCS code G2211 was delayed until January 2024 by the Consolidated Appropriations Act of 20214 and some commercial payers have not indicated whether they will recognize and reimburse this add-on service, the objective of this study was to examine adoption and appropriate use of the E&M visit complexity code G2211 by community urology practices in the first 6 months since its implementation. Further attention was given to use and reimbursement based on patient and clinician characteristics.
This retrospective study of anonymized claims did not constitute human subjects research, nor did it violate any human subject protections. Informed consent was therefore not required. Data for the study came from LUGPA, whose members contribute practice management data extracted from their billing systems (ie, claims data). The study and analysis were based on data from the completed claims of clinicians in 40 urology practices for visit dates from January 1, 2024, to June 30, 2024. Only claims that were fully adjudicated as of September 23, 2024, were included in the analysis. Claims from all specialties, financial classes, and payers were included in the study, and the information was appropriately modified to prevent the identification of individual patients and clinicians. All claims lines were included in our analysis, regardless of whether the service was denied or paid. We identified all E&M services and the encounters that were reported without modifier 25 (ie, “significant, separately identifiable evaluation and management [E&M] service above and beyond that associated with another procedure or service being reported by the same physician or other qualified health care professional [QHP] on the same date”) because, by policy, CMS does not allow payment for HCPCS code G2211 when the E&M code is reported with modifier 25.5 All diagnosis codes for each encounter were identified. Our principal outcome was the actual use of the code by clinicians across the first 6 months since the code’s implementation and by covariates of diagnosis, payer, region, and size of practice. Our secondary outcomes were (1) the frequency of claims payments for the submitted charge of HCPCS code G2211 by the same covariates and (2) average payment per claim. The cross-sectional analysis was performed using QlikView, version 12.10.0.0, software (QlikTech International AB).
A total of 1 938 108 office visits with an E&M service performed by 2305 unique clinicians in 40 unique independent urology practices were identified over the 6-month study period. The G2211 add-on code was used in 619 520 encounters: 30.9% of all E&M encounters and 38.0% of potentially eligible E&M encounters (total: 1 573 670) (Table 1). Use of the G2211 add-on code rose from 27.5% of all E&M encounters in January 2024 to 35.6% by June 2024, and its use in visits without modifier 25 rose from 33.2% to 41.9% over the same period (Figure 1). Inappropriate use of G2211 (billed on the same encounter as an E&M visit with modifier 25) remained relatively stable across the study period at 3.4% of G2211 services billed. By the end of the study period, 92% of G2211 claims submitted properly were paid a mean amount of $15.70 (Table 2). Payments for G2211 averaged $5995 per physician over the 6-month period and represented less than 1% of all payments during the study period.
Use of HCPCS code G2211 during eligible visits varied substantially across major diagnostic groups. The most common use of G2211 was during encounters for bladder cancer (53.3%) and prostate cancer (46.0%); the least common use was for encounters for erectile dysfunction (28.6%) and sterilization (5.4%). Fewer than 40% of G2211 claims for an encounter for sterilization were paid (Table 3). The add-on code was used more often (48.8% of eligible visits) and was reimbursed more frequently (96.2% of claims) and at a higher average rate ($15.99) in encounters for patients with Medicare than for patients with commercial insurance (28.2% of eligible encounters, 69.3% of claims, $13.19) or Medicaid (14.2% of eligible encounters, 22.6% of claims, $3.60). These reimbursement differences extended across all diagnostic groups (Table 4).
Table 5 outlines add-on code use and reimbursement by clinician characteristics. Use was highest (51.9%) in the Midwest region and lowest (29.2%) in the West. There were no notable differences in use or reimbursement by clinician’s years in practice or by practice size (<50 clinicians vs ≥50 clinicians). Add-on code use was lower for radiation oncologists than for clinicians of the other common specialties seen in large urology groups.
Despite decades of efforts to create value-based models of health care delivery, a fee-for-service system remains the dominant standard in the United States. Physician reimbursement is largely determined by applying a multiplier to the assigned relative value for a health care service to create a fee schedule. For example, CMS uses relative value units modified by geographic differences and a conversion factor to create the Medicare Physician Fee Schedule. Many commercial payers use either an identical system or contract with physicians to pay them a percentage of the Medicare-allowed fee. A single dictionary of services underlies the payment paradigm—the American Medical Association’s Current Procedural Terminology—and determines reimbursement across all specialties in medicine. Evaluation and management services are rendered by most physicians, and policymakers have attempted to refine the system to properly recognize inherent differences in the E&M services physicians perform for patients and cases of differing levels of complexity. The Office or Other Outpatient Evaluation and Management Visit add-on complexity code (G2211) is the latest example of these efforts.
Figure 1. Trends in HCPCS Code G2211 UseAbbreviations: E&M, evaluation and management; HCPCS, Healthcare Common Procedure Coding System.a“% G2211 inappropriate” refers to HCPCS code G2211 being appended to a claim that also used modifier 25.
Current law requires budget neutrality in the Medicare physician payment paradigm. If a new service code is introduced or an existing code revalued, other services as well as the conversion factor must be revalued to maintain neutrality; this process is typically done through annual rulemaking in the Medicare Physician Fee Schedule Rule. To make this calculation, CMS must estimate the use of new or revised codes. In the case of HCPCS code G2211, CMS initially estimated that the add-on code would be used for 100% of all office or outpatient E&M visits and published its estimates of use in the calendar year 2021 rule.6 After several rounds of public comment, their final estimate was that initial use of this code would be 38% of all office or outpatient E&M visits, rising to 54% when fully adopted.7 CMS estimated the portion of the total budget neutrality adjustment attributable to the office or outpatient E&M inherent complexity add-on code to be approximately 2.00%.8 Stakeholders are concerned that if these estimates are inaccurate, it could have a negative effect on the conversion factor or an unintended impact on the distribution of payments among specialties. Because CMS updates its estimates and fees only annually, early data on the use of the complexity code could be valuable.
Our analysis of urology practices showed 3 important findings: (1) possible underuse of the complexity code, (2) reduced reimbursement rates and payments for patients with commercial insurance compared with Medicare, and (3) lost financial opportunity for urology practices. Clinicians in community urology practices are using the add-on complexity code in less than one-third of all E&M visits and in approximately 38% of E&M visits when visits billed using modifier 25 are excluded across all diagnoses. Use of HCPCS code G2211 was furthermore seen in only 53% of potentially eligible E&M visits for bladder cancer and 46% of encounters for prostate cancer, serious conditions for which the urologist is often the focal point for longitudinal care. Based on the definition of the add-on code and the clarification rulemaking provided, we would expect HCPCS code G2211 use to be closer to 100% of potentially eligible encounters (ie, encounters for which modifier 25 is not used) for bladder cancer and prostate cancer in a urology practice. The apparent underuse may reflect an incomplete understanding of the new visit complexity code among urologists and suggests the need for specialty-wide education on its appropriate use. If these use patterns are seen across other specialties, there could be unintended impacts on budget neutrality adjustments (conversion factor) and uneven impacts on different specialties in future years.
Commercial insurance carriers do not always follow Medicare physician payment policies, and in this study only 69% of apparently appropriate G2211 commercial claims were reimbursed compared with 96% of Medicare claims; average payment was almost 19% lower for commercial claims than for Medicare claims. It will be important for policymakers to identify and address the reasons for this misalignment as clinicians and payers gain more experience with the complexity code.
Finally, this study highlights a potential lost opportunity for urology practices struggling with decreased reimbursement, increased practice expenses, and operational inefficiencies. Our analysis showed a mean annualized revenue of $12 000 per physician (approximately 1% of total revenue) from G2211 claims based on existing use and payments. Table 6 shows the potential financial impact of increased code use by condition. If appropriate use of the complexity code for only prostate cancer, bladder cancer, kidney cancer, elevated prostate-specific antigen, and incontinence—arguably serious conditions where the urology clinician is the focal point for longitudinal care—were increased to 75%, the potential incremental annual revenue would be $6490 per physician; at 100%, the revenue would be $11 622 per physician (almost double existing revenue). Based on existing reimbursement for the other conditions listed (eg, all payers reimbursed 90% of claims in the urinary tract infection diagnostic group), the potential revenue could be much higher.
Our study has many important limitations that come with using claims data to draw conclusions about health care utilization. This analysis reflects only 6 months of claims experience since the implementation of payment for this service, and adoption of the complexity code may not have reached a stable rate. Some commercial insurance carriers may not have had consistent payment policies in place during our study period. Our diagnostic groupings are based on the occurrence of International Statistical Classification of Diseases, Tenth Revision codes anywhere on the claim, and the group assignment may not reflect the principal reason for an encounter. For example, if a patient had a diagnosis of bladder cancer and sterilization on the same claim, they were counted in both diagnostic groups, and we were not able to discern the clinical reason for visit. Claims data are an incomplete source of information about the relationship between a clinician and a patient; for example, within a urology practice, a patient could see multiple clinicians for different serious conditions, yet all the encounters could carry the same diagnoses. Our data are sourced from adjudicated claims; we have no insight into the intentional omission of the complexity code because of insurance contracts, edits made before claim submission, who appended the code (clinician vs staff), or different practice billing workflows. We reported the percentage of claims that were paid but have no insight into reasons individual claims may have been denied. Our study is based in privately owned urology practices, and the findings may not be generalizable to academic or hospital-owned practices.
Urologists appear to be adopting the add-on complexity code for office or outpatient E&M visits at a lower rate than CMS estimated, especially in the treatment of patients with chronic conditions usually managed by urologists in a longitudinal relationship. Since the implementation of payment for this code, Medicare has been consistently reimbursing G2211 claims for those same conditions, while commercial payer reimbursement is less common and occurs at lower amounts. These use patterns may change as awareness is raised about the use of the code in treatment of patients with chronic urologic conditions. Appropriate use of this add-on code could result in substantial reward for specialists managing longitudinal care of their patients as intended by policymakers.
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. Fed Regist. 2023;88(220):78968.
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. Fed Regist. 2023;88(220):78970.
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. Fed Regist. 2023;88(220):78973.
Consolidated Appropriations Act, 2021, HR 133, 116th Congress (2019-2020). December 27, 2020. Accessed October 14, 2024. https://www.congress.gov/bill/116th-congress/house-bill/133/text
American Medical Association. Reporting CPT Modifier 25. CPT Assistant (Online). 2023;33(11):1-12. Accessed February 28, 2025. https://www.ama-assn.org/system/files/reporting-CPT-modifier-25.pdf
Medicare Program; CY 2021 payment policies under the Physician Fee Schedule and other changes to Part B payment policies final rule. Fed Regist. 2020;85(248):84572.
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. Fed Regist. 2023;88(220):78972.
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 proposed rule. Fed Regist. 2023;88(150):52699.
Published: March 31, 2025.
Conflict of Interest Disclosures: The authors have nothing to disclose.
Funding/Support: Dr Dowling received funding from LUGPA for his contribution to this article.
Author Contributions: All authors contributed equally to this article.
Data Availability Statement: Data sources are available upon reasonable request to the corresponding author.
Acknowledgments: The following collaborators are recognized for their contributions to this manuscript by critical review of the study proposal, acquisition of funding, and collection of data: Kirsten Anderson; David Carpenter; David Ellis, MD; Jason Hafron, MD; Jonathan Henderson, MD; Mara Holton, MD; Celeste Kirschner; Benjamin Lowentritt, MD; David Morris, MD; Timothy Richardson, MD; Cass Schaedig; Scott Sellinger, MD; and Jeffrey Spier, MD.
Citation: Dowling RA, Painter M, Goldfischer E. Office or other outpatient evaluation and management visit complexity code: early experience in community urology practice. Rev Urol. 2025;24(1):e113-e122.
Corresponding author: Robert A. Dowling, MD, Dowling Medical Director Services, 3820 Ridgehaven Rd, Fort Worth, TX 76116 (rdowling@dowling-consulting.com)