Since January 2024, primary care practices have been able to add G2211 to a Medicare office visit when the visit is part of a longitudinal relationship. Most of the practices we audit either bill it on almost nothing or on almost everything, and both are wrong. From January 1, 2025, the same practices can also bill one of three Advanced Primary Care Management codes each month for patients they manage. The two codes are related, they are both about the ongoing relationship, and they are both easy to bill incorrectly.
This is the coding guide we use in training. It reflects the CY2025 Physician Fee Schedule final rule published on November 1, 2024. Payment figures are the approximate national amounts CMS cited, before geographic adjustment; check your locality and your Medicare Administrative Contractor's 2025 fee schedule file when it posts.
Key takeaways
- G2211 is about the relationship, not the visit level. A 99212 for a ten-year patient qualifies; a 99215 for a one-time consultation does not.
- From January 1, 2025, G2211 is payable with modifier 25 only when the same-day service is an annual wellness visit, the IPPE, vaccine administration or another Part B preventive service. Other same-day procedures still block it.
- APCM is one code per patient per calendar month by one practitioner, leveled by chronic condition count and QMB status (about $15, $50 and $110), with no time requirement.
- APCM replaces CCM, PCM, TCM and the communication technology codes for that patient in that month; RPM, RTM and behavioral health integration remain separately billable.
- Build the claim edits before January, not after the first denial.
G2211: what it is and what it is not
G2211 is an add-on to an office or outpatient E/M visit (99202 to 99215) for Medicare Part B patients. It pays about $16 in 2024 and slightly less in 2025 after the conversion factor change. CMS describes two situations where it applies: the practitioner is the continuing focal point for all of the patient's needed health care services, or the practitioner is providing ongoing care for a single serious condition or a complex condition. The first describes primary care. The second describes, for example, an oncologist or a nephrologist managing one condition over time.
It is not a code for a complicated visit. A 99215 for a patient the practice will never see again does not qualify. A 99212 for a patient the practice has cared for over ten years does. The question is the relationship, not the level. A new patient visit can carry G2211 when the practitioner intends to assume the longitudinal role and documents that intent. Urgent care visits, walk-in visits by patients of other practices, and pre-operative clearances requested by a surgeon do not qualify, because there is no continuing relationship being served.
The modifier 25 rule and the 2025 exception
Through 2024, G2211 has not been payable when the E/M visit carried modifier 25. Starting January 1, 2025, CMS allows G2211 with a modifier 25 visit when the same practitioner performs the visit on the same day as an annual wellness visit (G0438 or G0439), the Initial Preventive Physical Examination (G0402), vaccine administration, or another Medicare Part B preventive service. The exception does not extend to other procedures.
| Same-day combination | G2211 payable in 2025? |
|---|---|
| 99214 alone, established primary care patient | Yes |
| 99214-25 with G0439 annual wellness visit | Yes (new exception) |
| 99213-25 with 90471 flu vaccine administration | Yes (new exception) |
| 99213-25 with G0101 and Q0091 preventive screening | Yes (Part B preventive service) |
| 99213-25 with 20610 joint injection | No |
| 99214-25 with 11102 skin biopsy | No |
| 99204 new patient, single consultation, no ongoing care planned | No |
| 99213 with 99401 counseling, no modifier 25 | Depends on the payer's edits; document the relationship |
G2211 documentation that survives an audit
CMS has not required a separate note. What a reviewer looks for is evidence, somewhere in the record, that the relationship exists: a problem list the practitioner maintains, a care plan, medication reconciliation, a history of visits, referrals coordinated by the practice. We tell providers to add one sentence to the assessment when they bill G2211 for the first time on a patient: "I am serving as this patient's continuing primary care physician and will coordinate ongoing care." After that, the record speaks for itself.
The audit risk runs the other way too. A practice billing G2211 on 100% of established visits, including the walk-in for a sprained ankle by a patient who sees a different PCP, is telling the payer its providers are the focal point for everyone who enters the building. Reviewers notice rates like that. A reasonable primary care practice bills G2211 on most, not all, established patient visits, and can explain the ones it skipped.
APCM: three codes, one patient, one practitioner, one month
Advanced Primary Care Management is billed once per calendar month per patient by a single practitioner. The level is set by the patient, not by time:
- G0556: one or fewer chronic conditions. National payment about $15 per month.
- G0557: two or more chronic conditions expected to last at least 12 months or until death, placing the patient at significant risk. About $50.
- G0558: two or more chronic conditions and Qualified Medicare Beneficiary status. About $110.
The billing practitioner must be the patient's continuing focal point for primary care (physician or non-physician practitioner) and the practice must be capable of delivering every service element in the code descriptor. Not every element has to be performed every month; the capability must exist and the elements must be furnished as the patient needs them. The elements are: patient consent; an initiating visit for new patients or patients not seen in three years; 24/7 access to care and continuity with a designated team member; comprehensive care management including assessment, medication reconciliation and preventive care oversight; an electronic patient-centered care plan available to the patient and the team; management of care transitions with timely follow-up; coordination with home and community-based providers; enhanced communication through secure messaging, email, portal or phone; population-level analysis of the panel; risk stratification; and participation in performance measurement through the Shared Savings Program, ACO REACH, Primary Care First or the Value in Primary Care MIPS Value Pathway.
Consent deserves a sentence. The patient must be told that only one practitioner can bill APCM for them in a month, that cost sharing applies (except for QMB patients), and that they can stop at any time. Document the consent once, in the record, with the date. Verbal consent documented by staff is acceptable; the practice needs to be able to show it.
What cannot be billed in the same month
APCM replaces the time-based care management codes for that patient. The same practitioner cannot bill, in the same month as APCM, chronic care management (99490, 99439, 99491, 99437, 99487, 99489), principal care management (99424 to 99427), transitional care management (99495, 99496), the interprofessional consultation codes, or the communication technology-based services (online digital E/M 99421 to 99423, the virtual check-in 98016, and remote evaluation of recorded images G2250). Remote physiologic monitoring and remote therapeutic monitoring are not on the list and remain separately billable. Behavioral health integration codes are also separately billable. Read the final rule's table rather than trusting a summary, including this one, when you build the claim edit.
Worked examples
Example 1. A 71-year-old established patient with hypertension, type 2 diabetes and chronic kidney disease stage 3 is seen in January for a 99214 visit; the practice has enrolled her in APCM with documented consent in December. Claim for the visit: 99214 plus G2211 (longitudinal primary care relationship). Claim at month end: G0557. The practice did not bill CCM for her in January, and the care coordinator's time is not counted, because APCM has no time requirement.
Example 2. The same patient in February has no visit but the care coordinator manages a hospital discharge, reconciles medications and updates the care plan. Claim: G0557 only. No TCM, because APCM covers transition management for an enrolled patient.
Example 3. A 68-year-old patient with hypertension only, enrolled in APCM, comes in for an annual wellness visit and mentions worsening knee pain, which the physician evaluates and treats with a prescription. Claim for the visit: G0439, 99213-25, G2211 (the 2025 exception applies because the modifier 25 visit is with an AWV). Month end: G0556.
Example 4. A patient with two chronic conditions whose eligibility response shows the QMB indicator. Month end: G0558. The practice may not bill the patient for Medicare cost sharing; QMB patients are protected from it, which is why CMS values the code higher.
Example 5. An enrolled patient with two chronic conditions sends a portal message in March about a medication side effect, and the physician spends eight minutes reviewing the chart and replying with a dose change. Claim: G0557 at month end, and nothing else. The online digital E/M code 99422 that would have applied in 2024 is bundled into APCM for an enrolled patient.
Setting up APCM in the practice
The setup work is mostly organizational, and the two elements that trip practices up are 24/7 access with access to the record, and participation in a qualifying performance measurement program. A practice that has neither should solve those first, because without them the codes are not billable regardless of how good the care coordination is. The rest is counting and configuration: the Medicare panel by number of chronic conditions and QMB status (the QMB indicator appears in the Medicare eligibility response and on the remittance), a consent script, a claim edit that allows one APCM code per patient per month and blocks the bundled codes from the same practitioner, and a rule for who bills in a group, which is the PCP of record, so the practice needs a reliable way to know who that is for every patient.
Questions we hear
Do commercial payers and Medicare Advantage plans pay G2211 and APCM?
G2211: some MA plans do, most commercial plans do not, and the position varies by plan year. APCM: the codes are new and MA plans will publish their positions over the coming months. Bill Medicare Part B first and confirm each MA plan in writing before you build them into the workflow.
Is APCM worth more than CCM for our practice?
It depends on your panel. For a patient with two or more conditions who currently generates 20 minutes of CCM most months, APCM pays less per month but requires no time tracking and covers months where little happens. For a practice that never billed CCM because time tracking was the barrier, APCM is new revenue for work already being done. Model it on your own panel before deciding: count patients by level, multiply by the monthly amounts, and subtract what CCM and TCM brought in last year.
Can we bill G2211 on every established patient visit?
No. Bill it where the relationship exists and the record shows it. A practice billing G2211 on 100% of visits, including walk-ins and one-time consultations, will draw attention. Revelrex reviews G2211 and care management coding as part of the medical coding service, and the January session of our RCM training works these examples on realistic charts in the Revelrex EHR.
What to do this month
- Count the Medicare panel by number of chronic conditions and QMB status, and estimate APCM revenue by level against last year's CCM and TCM.
- Confirm the practice can show 24/7 access with record access and participation in a qualifying performance measurement program; if not, decide whether to pursue them.
- Write the consent script and the documentation line, and decide who obtains and records consent.
- Build the claim edits: one APCM code per patient per month; no CCM, PCM, TCM, interprofessional or communication technology codes from the same practitioner in that month; G2211 allowed with modifier 25 only in the preventive-service scenario.
- Identify the PCP of record for every Medicare patient and fix the ones that are blank.
- Train providers on the five examples above in the last two weeks of December, before the first January claims go out.
