Academy Renews Push for Medicare Add-on Code
Feb. 13, 2023, News Staff — In a Feb. 2 letter to CMS, the AAFP renewed its advocacy for adoption next year of a Medicare code that values the complexity of primary care and other office and outpatient evaluation and management visits.
“The AAFP strongly supported the creation of G2211 and urges CMS to ensure its full implementation in 2024,” the Academy said.
In the agency’s definition, Code G2211 describes “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.”
For family physicians, that translates precisely to the continuous, comprehensive, coordinated primary care they give their patients — care for which Medicare has historically underpaid.
CMS finalized G2211 in 2021, alongside E/M code updates for which the AAFP had successfully pushed, but Congress halted its implementation. Through Dec. 31 of this year, the code remains in “bundled status,” which allows physicians to bill for G2211 but does not provide separate payment for it.
With that moratorium set to end and the AAFP setting appointments with CMS staff to discuss this and other 2024 payment priorities, the letter also called on the agency to “reexamine its utilization assumptions based on implementation experience with other new codes,” including several to which the letter pointed.
Those examples, the Academy suggested, could help CMS reduce estimates for G2211 use — in turn lowering the projected increase to Medicare spending and related budget-neutrality adjustments that could otherwise emerge in the 2024 Medicare physician fee schedule.
Filling a Gap
“Evidence clearly demonstrates that primary care office/outpatient E/M visits are more complex and comprehensive than other E/M visits,” the Academy wrote. But the office/outpatient visit E/M code set doesn’t adequately describe coordinated, team-based primary care.
This leaves a gap that G2211 must fill. The Academy backed its case with several studies, including 2015 research indicating that “family medicine and general internal medicine encounters were more complex compared to other specialties.”
CMS has acknowledged this itself, the letter noted, quoting the agency’s own words in the 2021 MPFS final rule: “We continue to believe that the typical visit described by the revised and revalued office/outpatient E/M visit code set still does not adequately describe or reflect the resources associated with primary care … We continue to believe that the time, intensity and practice expense involved in furnishing services to patients on an ongoing basis that result in a comprehensive, longitudinal and continuous relationship with the patient and involves delivery of team-based care that is accessible, coordinated with other practitioners and providers, and integrated with the broader health care landscape, are not adequately described by the revised office/outpatient E/M visit code set.”
“The AAFP wholeheartedly agrees with CMS,” the letter said.
Utilization Estimates
In the 2021 MPFS final rule, CMS said it expected that G2211 would be billed with 90% of office/outpatient E/M codes provided by family physicians “and other specialties that provide primary care or certain types of specialty care.”
“The AAFP continues to believe this utilization assumption is unrealistic and should be modified,” the Academy wrote, expressing strong concern that inflated utilization predictions would lead to unfavorable budget neutrality adjustments in the 2024 MPFS, and, ultimately, to lower pay.
For a truer estimate that is less likely to impede full implementation of G2211, the Academy urged CMS to examine other new codes that were implemented in recent years — specifically, first-year data for codes devoted to management of chronic care, principal care and transitional care.
“A recent study found that in 2016 (the second year of implementation), 2.3% of Medicare beneficiaries had claims for chronic care management services even though two-thirds of beneficiaries were eligible for such services,” the letter said. “The same study found that 22% of Medicare beneficiaries were eligible for transitional care management services, but only 9.3% of eligible beneficiaries had claims for TCM filed.”
The AAFP pointed out that family physicians in certain settings will have some patient visits that are not part of continuous ongoing care, so they will not bill G2211 with every office/outpatient E/M encounter. In addition, many of the specialties CMS assumes will use G2211 will regularly have encounters with patients that are not part of continuous care related to a single serious condition.
“We strongly urge CMS to modify its utilization assumptions to account for these considerations. CMS notes in the final rule that the use of G2211 could be audited using claims data to determine if ongoing care is provided or whether the patient has a single serious condition,” the letter said. “Even without explicit policies restricting the use of the code, we believe practitioners will limit their use of G2211 to patients and encounters for which it is clearly appropriate to bill in order to protect against audits or other concerns from CMS.”
Relativity and Equity
“CMS is charged with maintaining the relativity of the MPFS, or ensuring that payment for services that require more resources to furnish are higher than for services that require fewer services,” the letter said. “While the updated office/outpatient E/M codes more appropriately value the care provided during an office visit, the existing processes for creating, describing and valuing these codes do not account for unique costs borne by primary care and other physicians providing longitudinal, patient-centered care.”
Implementing G2211 will better reflect the costs of providing high-quality, longitudinal primary care, the AAFP said.
The letter reminded CMS that implementation also would advance several of the agency’s strategic priorities “by stabilizing and strengthening community-based primary care practices, increasing connections to primary care and addressing health disparities.”