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Reimbursement for additional office/outpatient services billed with E&M and add-on code G2211
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Governs Healthfirst reimbursement rules when preventive services and Evaluation and Management (E&M) services or qualifying add-on code G2211 are billed on the same date for the same member by the same provider across specified lines of business.
The G2211 section was revised to align with New York State Medicaid coverage requirements and Healthfirst reimbursement policies effective June 1, 2026.
Added NYS Medicaid pediatric coverage for HCPCS code G2211 for members ages 0-20 years with related billing requirements.
Added telehealth billing requirements permitting reimbursement of G2211 when billed per NYS Medicaid telehealth rules and with telehealth modifiers.
Clarified that G2211 and G2212 are add-on codes and should not be billed with Modifier 25; claims with Modifier 25 will be denied.
The G2211 section was revised to align with New York State Medicaid coverage requirements and Healthfirst reimbursement policies effective June 1, 2026.
Created a standalone policy section for G2211 to distinguish visit complexity services from prolonged services reported with G2212.
Added coverage for HCPCS code G2211 for Medicaid members ages 0-20 years in accordance with NYS Medicaid guidance.
Added billing requirements, including reporting G2211 with a qualifying E&M service, allowance for preventive medicine visit codes, limitation of one unit per patient per week, and eligible POS codes 02, 10, 11, and 22.
Added telehealth billing requirements clarifying G2211 is reimbursable via telehealth when billed per NYS Medicaid rules and with required modifiers 93, 95, or GT.
Added adult Medicaid limitation clarifying G2211 is not separately reimbursable for Medicaid members age 21 and older.
Coverage Criteria and Eligibility
Preventive exam + E&M and G2211 coverage criteria
Covered when ALL of the following are met:
ALL of the following
- When a significant, separately identifiable E&M office/outpatient service (CPT 99202-99215) is performed on the same date as a preventive medicine examination, the E&M must be billed on the same claim and include Modifier 25.
- E&M services billed with Modifier 25 on the same date as a preventive medicine examination will be considered for reimbursement but will be reimbursed at 50% of the provider's contracted allowable amount unless documentation justifies full payment.
- Documentation must support that the E&M is significant and separately identifiable from the preventive examination, clearly distinguish preventive versus problem-oriented services, support the level of E&M billed, and demonstrate medical necessity for the additional service.
- An E&M service may be denied when documentation does not support a separate and distinct service, duplicates routine preventive components, or Modifier 25 is appended without sufficient justification.
ANY of the following
- Diagnostic tests, laboratory services, immunizations/vaccines, and procedures are not subject to the 50% reduction and remain separately reimbursable when billed appropriately.
LOB reimbursement rules
Line-of-business reimbursement and documentation criteria:
ALL of the following
ALL of the following
- G2212 may be eligible for separate reimbursement when reported with a qualifying E&M service and supported by documentation that meets CMS requirements for prolonged services.
- G2211 may be eligible for separate reimbursement when reported with a qualifying E&M service and supported by documentation that meets applicable CMS coding and documentation requirements.
Documentation criteria
Documentation requirements for add-on codes:
ALL of the following
- Medical record must support the medical necessity of the E&M service and an ongoing clinician-patient relationship.
- Must document longitudinal care management of a serious or complex condition and how the visit fits within the patient's ongoing plan of care.
ALL of the following
- No additional documentation beyond the base E&M visit is required; however, the medical record must support medical necessity of the E&M service.
ALL of the following
- Documentation must support level of service billed and clearly distinguish preventive versus problem-oriented components when services are provided the same day.
NYS Medicaid pediatric & telehealth coverage
NYS Medicaid pediatric and telehealth specifics for G2211:
ALL of the following
- Member is a New York State Medicaid member age 0–20 years.
- Service is furnished by an eligible physician or nurse practitioner practicing in pediatric primary care or a pediatric subspecialty.
- G2211 is reported on the same date of service with a qualifying E&M code; preventive medicine visit codes are allowable companions.
- Billing does not exceed one unit per patient per week.
- Place of service on the claim is one of: 02, 10, 11, or 22.
- When provided via telehealth, G2211 is billed in accordance with NYS Medicaid telehealth rules and appended with modifier 93, 95, or GT as required.
ALL of the following
- G2211 is not separately reimbursable for Medicaid members age 21 and older; claims will be denied.
ALL of the following
- Report G2211 only with a qualifying E&M service; ensure POS and telehealth modifiers comply with NYS Medicaid billing rules.
G2211 Coverage Criteria
Coverage and billing criteria for G2211 under New York State Medicaid as adopted by Healthfirst:
ALL of the following
- Medicaid members age 21 years and older: G2211 is not separately reimbursable and claims will be denied.
ALL of the following
- Eligible physicians and nurse practitioners practicing in pediatric primary care and pediatric subspecialties may bill G2211 for covered members.
ALL of the following
- G2211 must be reported with a qualifying E&M service (CPT 99202–99205 or 99211–99215); it is an add-on code and cannot be billed as a standalone service.
- G2211 should not be billed with Modifier 25; claims with Modifier 25 appended to the add-on will be denied.
- Allowable companion codes include preventive medicine visit codes when appropriate.
ALL of the following
- Limit one unit of G2211 per patient per week.
- Eligible place-of-service codes: 02, 10, 11, 22.
ALL of the following
- G2211 reimbursable via telehealth when billed in accordance with NYS Medicaid telehealth rules and appended with modifier 93, 95, or GT; must bill with an eligible POS and comply with telehealth billing requirements.
ALL of the following
- Claims that do not adhere to these requirements will be denied or rejected; reimbursement is subject to member eligibility, provider contract, fee schedule, and Healthfirst policies.
Codes, Modifiers, and Frequency Limits
| Modifier 25 | Significant, separately identifiable E&M service on same day as preventive visit |
| G2211 | Add-on code for visit complexity inherent to evaluation and management serving as ongoing focal point of care or part of ongoing care for a single serious/complex condition |
| G2212 | Add-on code for prolonged office or other outpatient E&M services beyond maximum time of primary service; per additional 15 minutes |
| 99205 | Office/outpatient E&M new patient, high level (qualifying for G2212 pairing) |
| 99215 | Office/outpatient E&M established patient, high level (qualifying for G2212 pairing) |
| G2211 | Office/outpatient evaluation and management visit complexity add-on |
Provider Billing, Documentation, and Adjudication Actions
Bill preventive exam and E&M together; use Modifier 25
When both a preventive medicine examination and an E&M service are performed on the same date of service, bill both services on the same claim and append Modifier 25 to the E&M. Reimbursement remains subject to member eligibility, provider contract and fee schedule, and Healthfirst policy; documentation must support that the E&M is significant and separately identifiable from the preventive service.
- Bill preventive medicine exam and E&M on same claim.
- Append Modifier 25 to the E&M service.
- Maintain documentation demonstrating the E&M is significant and separately identifiable.
Noncompliant claims risk denial; final payment subject to adjudication
Claims that do not adhere to this policy may be denied or rejected. Final reimbursement decisions depend on benefit coverage, state/federal mandates, medical necessity, and the provider contract; providers are responsible for accurate coding and should contact their designated Healthfirst contact with questions.
- Noncompliant claims may be denied or rejected.
- Final payment is subject to member benefits, mandates, medical necessity, and contract terms.
- Contact your designated Healthfirst representative for clarification.
Bill G2212 only with 99205/99215 and when time thresholds exceeded
Bill G2212 only when paired with qualifying high-level E&M codes (99205 or 99215) and only if total physician or qualified health care professional time on the date of service exceeds the maximum time threshold for the primary E&M service.
Billing constraints for G2211: pairing, unit limits, POS, telehealth modifiers
Report G2211 only with a qualifying E&M service (preventive medicine visit codes are allowed); limit to one unit per patient per week, bill with eligible POS codes 02, 10, 11, or 22, and when provided via telehealth append the required telehealth modifier (93, 95, or GT) to the qualifying E&M in accordance with NYS Medicaid billing rules.
- G2211 may be billed with preventive medicine visit codes when paired with a qualifying E&M.
- Limit G2211 to one unit per patient per week.
- Use eligible POS codes 02, 10, 11, or 22.
- When delivered via telehealth, append modifier 93, 95, or GT to the qualifying E&M and follow NYS Medicaid telehealth rules.
Definitions and Coding Principles
Policy Revision History
Revised G2211 section to align with New York State Medicaid coverage requirements and Healthfirst reimbursement policies effective June 1, 2026; separated G2211 from G2212; added NYS Medicaid pediatric coverage (ages 0-20), billing requirements (report with qualifying E&M, allowance with preventive medicine visit codes), one-unit-per-week limit, eligible POS codes (02,10,11,22); added telehealth billing requirements including modifiers 93, 95, GT; clarified G2211 is not separately reimbursable for Medicaid members age 21 and older.
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