By Carrie Arnold

A long-awaited Medicare add-on billing code not only boosted pay for primary care physicians but also helped specialists, researchers found in a new study that’s likely to reignite debate over whether the code is working as intended.

The analysis of Medicare claims data found that in 2024, its first year of use, the G22111 code was billed 26 million times for 10.6 million patients, generating about $394 million in payments.

But specialists billed more G22111 codes than primary care physicians, the study found.

First author Ishani Ganguli, MD, MPH, a primary care physician at Mass General Brigham and health services researcher at Harvard Medical School, Boston, said she was disappointed but not surprised that specialists most frequently used a code that was developed to help primary care.

“It was really meant to try to provide an additional payment for doctors providing longitudinal care and holistic care,” Ganguli said.

This study “demonstrates that even when policymakers aim to strengthen primary care payment, broad, specialty-neutral fee schedule changes can be adopted across specialties in ways that dilute the intended impact,” the American Academy of Family Physicians said in a statement.

A Pay Bump for Primary Care

The G2211 code was first introduced in 2021 as part of Medicare’s Physician Fee Schedule for physicians, its text indicating that it was meant to boost compensation for providers “serving as the continuing focal point for all of the patient’s healthcare services needs” or providing “ongoing medical care related to a patient’s single, serious…or complex condition (eg, sickle cell disease).”

Andrew Lyman-Buttler, MD, a third-year family medicine resident at the University of Minnesota, said that code’s reimbursement of $16.04 compensates doctors for the cognitive labor of following patients with complex diseases such as hypertension, diabetes, or polycystic ovary syndrome.

Although the dollar amount isn’t much, Lyman-Buttler said, it adds up over time, recognizing the otherwise unbillable work and other care physicians provide behind the scenes.

“Its purpose is to level the playing field a bit between what are sometimes called the procedural and the more cognitive specialties,” he said. “It’s sort of a little bone that they’ve thrown us.”

Medicare rules prohibit the creation of specialty-specific billing codes, Ganguli said, which meant the agency was unable to restrict G2211 solely to primary care.

That’s not necessarily a bad thing, said Shari Erickson, MPH, chief advocacy officer at the American College of Physicians, as many specialists also provide long-term patient care for patients with complex conditions.

Still, said Dartmouth University pediatrician Andrew Schuman, MD, medicine needs a better way to compensate primary care clinicians for the work that they do.

“Primary care is the base of a pyramid where we generate a lot of services and generate a lot of revenue for institutions and for specialists. So we generate referrals to specialists, we order a lot of tests, and so forth. It generates a lot of revenue,” Schuman said. “It’s an important code because it emphasizes the importance of providers in coordinating care.”

Some associations of specialist physicians opposed the adoption of G2211 because improving payments to primary care would decrease payment to other areas of medicine.

Think of the money Congress sets aside for Medicare reimbursement as a pie, said Sara Pastoor, MD, MHA, a physician who leads Primary Care Advancement at Elation Health.

Because Medicare physician payments must remain budget neutral, increasing reimbursement for longitudinal care through G2211 requires reductions elsewhere to offset the increases, prompting concerns among specialty groups about redistribution of payments. It’s why 19 surgical societies authored a letter to the director of the Centers for Medicare & Medicaid Services (CMS) in July 2023 arguing that “this code will inappropriately result in overpayments to those using it while at the same time penalizing all physicians due to a reduction in the Medicare conversion factor that will be required to maintain budget neutrality under the PFS.”

Despite this opposition, Congress green-lit the implementation of G2211 as part of a 2023 spending bill.

The sometimes contentious debate over G2211, combined with uncertainties as to whether the code would have the desired effect, led Ganguli and colleagues to measure how physicians used the code in their day-to-day practice.

Specialist physicians, including urologists, nephrologists, endocrinologists and rheumatologists, billed 43% of the 26 million G2211 codes in 2024, followed by primary care physicians, who billed 39.7% of the codes. However, primary care physicians used G2211 for one quarter of their eligible visits compared to specialist physicians, who used G2211 for only 13% of their eligible visits.

That one quarter of physicians used G2211 and that the billing code was used on 14.5% of all appropriate visits in the code’s first year was higher than Ganguli expected but less than Medicare’s estimated uptake of 38% of eligible visits in the first year. CMS predicted that number would move toward 54% of visits as doctors increased their familiarity with G2211.

“It’s very easy to count the number of gauze pads, but when you’re talking about really complex management of patient, it’s much harder to capture that in our current system,” said Erickson. “G2211 is a small step toward more appropriate payment for the services that primary care physicians and other clinicians provide.”

Pastoor agrees that G2211 is only the first step toward improving compensation for primary care.

“Primary care really has been undervalued and underpaid for a long time,” Pastoor said. “If you are managing a problem longitudinally, you’re doing a lot of extra coordination of care. $16 probably doesn’t cover it, but it helps.”