Decoding What’s Going on With G2211 and Modifier 25

Following the AAFP’s big win on G2211 at the end of 2023 and the Jan. 1 implementation of that Medicare add-on code — which pays more accurately for the complex, high-value visits that primary care physicians provide as part of a continuous relationship with a patient — the Academy started hearing from members who are frustrated by a wrinkle in the new policy: its exclusion from evaluation and management visits for which family physicians are used to coding modifier 25. 

As I said in this blog last November, the 2024 Medicare physician fee schedule says clinicians cannot bill G2211 alongside modifier 25 (which is used when performing a procedure or providing some other service, such as the Medicare annual wellness visit, on the same day as an E/M visit). Last summer, the Academy asked CMS to create an exception for annual wellness visits that would allow clinicians to use both G2211 and modifier 25; the final 2024 MPFS did not take up this guidance. 

So this month, we continued to make our case for CMS to correct this problem in the upcoming 2025 Medicare physician fee schedule, pointing out inconsistencies in CMS’ policy and zeroing in on how crucial it is for family physicians to be able to use G2211 in tandem with modifier 25.

“The AAFP urges CMS to allow payment for G2211 when attached to an E/M visit appended with modifier 25,” said our Feb. 7 letter. “We support the goals of the G2211 add-on code and are very concerned that the restriction on visits with modifier 25 works against those goals by preventing family physicians from receiving the resources needed to account for the complex care that serves as the continuing focal point for all needed health care services they provide to Medicare beneficiaries in office E/M visits. Further, the policy creates incentives to offer fragmented care.” 

To fix this issue, our letter called on CMS to  

• eliminate restrictions on the payment of G2211 when modifier 25 is attached to the E/M code, “to ensure family physicians can continue to offer Medicare beneficiaries comprehensive services in a single visit;” and 

• allow G2211 to be applied to home and residence evaluation and management services to more accurately reflect the value of comprehensive primary care home visits. 

The letter is just the initial salvo in our advocacy for the 2025 MPFS, and it reflects feedback the Academy has received from members in the wake of G2211’s implementation. The AAFP is also in touch with private payers about G2211. 

We know that a big reason behind your frustration is the prohibition of G2211 payment alongside modifier 25 when the E/M visit is entirely consistent with CMS’ thinking on G2211. For example (and as we just reminded CMS), more than 75% of the time it’s a family physician or an internist handling the AWV — as you would expect for the centerpiece visit for a patient’s most necessary health care. So why shouldn’t G2211 also apply to an E/M service that happens in the same visit as the AWV, or any other service or procedure?  

The short answer: It should.  

Right now, Medicare requires modifier 25 to be appended to the E/M code to indicate that the E/M service was “significantly and separately identifiable” from another procedure or service reported by the same physician on the same date. Yet we know that Medicare beneficiaries often arrive at an appointment with many separate needs and rely on their family physicians to address those needs that day. To deny payment for G2211 unfairly penalizes physicians who deliver comprehensive care alongside an AWV, other preventive services and other procedures. It’s antithetical to the intent of G2211.   

To emphasize this point, the Academy pointed to CMS’ own “How to Use the Office & Outpatient Evaluation and Management Visit Complexity Add-on Code G2211.” An example in that document shows G2211 billed to reflect complexity not otherwise accounted for in an E/M visit when a physician sees a patient for sinus congestion and provides recommendations — the kind of interaction that’s integral to longitudinal primary care. 

“If the physician also persuades the patient to receive a vaccine (to prevent future illness) during the same visit, the physician would be unable to bill for G2211 because modifier 25 is required to report the immunization service on the same day as an E/M visit for sinus congestion,” we told CMS. 

We also cited an example from an AAFP member. 

“When a family physician trims the toenails of a patient with diabetes, they are unable to bill G2211 because the additional procedure requires modifier 25 be appended to the office/outpatient E/M visit,” the member wrote. “The family physician is penalized for offering comprehensive, same-day services to care for their patient — care that reinforces the physician’s longitudinal relationship with the patient as their primary source of care. 

“The current policy inadvertently reduces the incentive for physicians to fully address patient needs in a single visit. Returning for a second visit would also unfairly penalize Medicare beneficiaries who face additional out-of-pocket costs and spend additional time visiting the physician’s office a second time.” 

As we’ve often talked about in this space, budget neutrality — the stipulation that CMS can’t raise payment in any area of the MPFS without lowering it somewhere else — is a key obstacle here. With the meter running on Congress’ most recent continuing resolution to fund the government, the AAFP is again urging lawmakers to fix this outmoded mandate, which stifles investment in primary (and other medical) care and fails beneficiaries.  

Even absent such a correction, however, we’re arguing that CMS could, at minimum, reduce restrictions on the use of G2211 when preventive services are provided during an office visit for E/M services. For example, allowing G2211 payment with E/M services when modifier 25 is reported with common preventive services would put the total increase in Part B allowed charges at about $121 million, a reduction to the conversion factor of no more than about 0.1% to maintain budget neutrality — not an extraordinary price for achieving what’s in the best interest of Medicare beneficiaries and the primary care physicians who provide these valuable services. And eliminating the modifier 25 exclusion starts to look even more doable if CMS, as we’ve asked, examines actual 2024 utilization of G2211, which is likely to be lower than anticipated due to the large number of outpatient/office E/M visits reported with modifier 25 that are ineligible for G2211 payment. 

Besides advocating for more realistic use of G2211 and modifier 25, our Feb. 7 letter called for the 2025 Medicare physician fee schedule to  

• make permanent coverage of both audio-video and audio-only telehealth services for all beneficiaries regardless of geography; 
• pay telehealth services reported with either place of service 10 or 02 at the non-facility rate; and 
• expand the primary care exception — which permits a teaching physician to bill for some lower and midlevel complexity physicians’ services furnished by residents in specific types of residency training settings, even when the teaching physician is not present with the resident, if certain conditions are met — to include additional codes, as we have long advocated.  

“Permanently expanding the primary care exception could help improve utilization of recommended preventive care services, which is particularly important as many patients are still catching up on preventive care they may have forgone throughout the pandemic,” we noted. 

We are meeting with CMS leaders to discuss G2211 and how eliminating the modifier 25 policy is critical to achieving the goals of G2211 payment — advocacy that will continue until there is a solution. 

Family Medicine Advocacy Summit 

Registration remains open for our 2024 Family Medicine Advocacy Summit, May 19-21 in Washington, D.C. This is our biggest in-person advocacy event of the year, where AAFP members join colleagues in their chapters for face-to-face conversations with members of Congress about the Academy’s top legislative priorities. In an election year when we’re already working on some pivotal issues, I can’t overstate the value of your participation.  

Another Way to Be Heard About Payment

In November, I put in a plug for the Physician Practice Information Survey, which gathers data on practice costs helping us advocate to improve physician payment. It’s run by the AMA, in tandem with the consulting firm Mathematica, and endorsed by more than 170 medical societies and other health care associations.  

In late January, the AMA sent nearly 10,000 physician practices a reminder to complete the survey. Practices chosen to participate will see the return address ppisurvey@mathematica-mpr.com and a priority mail packet from Mathematica with a link to the survey and supporting information. If you received this email, please fill out the survey. The information you provide — about the time you spend on patient care each week — is extremely important to the AAFP’s push for accurate payment.