What diagnosis is required to bill CPT G2211 complexity add-on code?

The diagnosis is not the only determining fact for using G2211. The codes description reads:

“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)”

Review each case and determine if the following criteria are met:

• Medicare Part B patient
• Office or outpatient E/M visit
• Modifiers 25, 24, or 53 are not billed on the same day.
• The primary reason for the visit is a single, serious, or complex condition:
  • Chronic uveitis, glaucoma, age-related macular degeneration (AMD), ocular oncology, etc.
  • Not an acute or time-limited condition, or one that is resolved with intervention (e.g., corneal abrasion, cataract, epiretinal membrane (ERM), etc.)
• The ophthalmologist is the managing physician providing ongoing medical care for this condition.
• Documentation supports the use of G2211.
  • Includes key words to help support visit complexity (e.g., therapeutic goals, patient-physician shared commitment to reach goals)

Access the Academy’s Fact Sheet at HCPCS Code G2211 Visit Complexity Add-on Code

See also First Coast and Novitas Report Improper Billing of G2211