CMS wants providers to get the message that if they bill for outpatient or office visits with modifier 25, they should forget about adding the inherent complexity add-on code (G2211) that is payable starting Jan. 1.
The point was driven home in Medicare Transmittal 12,370, which was released Nov. 21.[1] In both the transmittal and the 2024 Medicare Physician Fee Schedule (MPFS) rule, which activated the complexity add-on code, CMS said claims will be denied if G2211 is reported with modifier 25 for the same date of service as an office/outpatient evaluation and management (E/M) visit (codes 99202-99205, 99211-99215) for the same beneficiary. The modifier—a compliance thorn in providers’ sides—is used to report a significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service.
CMS is paradoxically both tightening and loosening the noose on the use of G2211 with payment modifiers, said Richelle Marting, an attorney and certified coder in Olathe, Kansas. On the one hand, 2023 updates to Chapter 12 of the Medicare Claims Processing Manual put more restrictions on billing with the complexity code because they went beyond modifier 25.[2] “We do not expect reporting of HCPCS code G2211 when the office/outpatient E/M visit is reported with payment modifiers such as a modifier -24, -25, or -53,” the manual states. On the other hand, that language is gentler—CMS said it doesn’t “expect” reporting of the modifier—than the new transmittal, which makes it clear that Medicare administrative contractors (MACs) will deny claims but only with respect to modifier 25. There’s a twist: the manual instructions were written for the complexity add-on code at a time its use was prohibited by Congress and before the proposed and final 2024 rules were released. CMS planned to start payment for the complexity code in 2021, but Congress put that on ice until no earlier than next year. And now, a month before the code will finally go live, CMS has tweaked its application in relation to the modifiers.
