E/M add-on G codes are used to report additional services beyond the basic evaluation and management (E/M) codes. These codes are typically used in conjunction with primary E/M codes to provide more detailed information about the patient’s condition or to document additional services that were provided.
To correctly report E/M add-on G codes, you should follow these steps:
- Determine the primary E/M code: The first step is to identify the primary E/M code that best describes the level of service provided. This code will be used as the basis for reporting the additional services.
- Identify the appropriate add-on code: Once you have determined the primary E/M code, you can identify the appropriate add-on G code based on the specific service provided. There are several different add-on G codes, each of which corresponds to a specific type of service.
- Report the add-on code: The add-on code should be reported in conjunction with the primary E/M code. The add-on code should be listed after the primary code, with a “+” symbol between them.
- Provide documentation: It is important to provide clear and detailed documentation of the additional service provided. This documentation should support the use of the add-on code and should be included in the patient’s medical record.
Here is an example of how to report E/M add-on G codes:
Suppose a physician provides a level 4 office visit for a patient with a complex medical condition, and also spends an additional 30 minutes counseling the patient about their treatment options. The appropriate codes to report would be:
- 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity)
- G2212 (Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service)
These codes should be reported as: 99214+G2212. The documentation should clearly describe the additional counseling provided by the physician.