G2211 Documentation

G2211 Documentation

Last month’s blog explained HCPCS G2211, its appropriate use, and inappropriate use.

HCPCS G2211 – 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[1]

In follow up, some asked what the documentation may look like to support submission of this code.  An example could be a patient who suffered a dislocated shoulder with related nerve damage and subsequent numbness in their upper extremity.  The note describes that an EMG demonstrated areas of no nerve function.  The note also describes the discussion of treatment options and that the decision was made to attempt therapy and hope that nerve function returns but if it doesn’t surgical repair is an option.  An example of added documentation that may support submission of G2211 is:

This patient’s injury and subsequent pathology of the upper extremity is a complex condition.  This complexity is created by the complications of the injury, the degree to which it is impacting life, and the risks involved with some of the options being considered, particularly the surgical options.  The medical care services provided by me today carry with them complexity that is inherent to today’s evaluation and management of this complex condition.  Furthermore, the care provided today represents longitudinal care as this service was part of ongoing care for this problem that requires a “consistent and coherent approach to the management of a health condition that is responsive to a patient’s changing needs.”  Therefore, HCPCS code G2211 was submitted with this encounter.

[1] https://www.cms.gov/medicare/regulations-guidance/physician-self-referral/list-cpt/hcpcs-codes

Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA

Dr. Lehrman is a Board Certified Podiatrist, Certified Professional Coder, and Certified Professional Medical Auditor. He is in private practice in Colorado and operates Lehrman Consulting, LLC which provides consultation services regarding coding, compliance and documentation.

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