G2211 may be headed for its biggest change since Medicare began paying it. In the proposed 2027 Medicare Physician Fee Schedule, CMS would transition G2211 from a separately billed HCPCS add-on code to a two-character modifier appended to the qualifying evaluation and management service.

That may sound like a technical claim-format change. It is not. The proposal would also replace today’s flat add-on payment with a percentage of the underlying E/M payment. Depending on a practice’s E/M mix, the change could increase revenue, reduce it or simply shift where that revenue is earned.

After nearly three decades in medical billing, I have learned that the practices most affected by a rule change are often not the ones billing incorrectly. They are the ones that wait until January to update workflows, train providers and test their systems. This is one change practices should prepare for now—without treating a proposal as a final rule.

What CMS is proposing for 2027

CMS has proposed two major changes:

1. Replace the separate G2211 claim line with a modifier. CMS is currently using the placeholder “MOD1.” If finalized, it would be replaced by an official two-character HCPCS modifier.
2. Pay 16% of the associated E/M service instead of one flat amount. This would make the complexity payment proportional to the level and allowed amount of the qualifying E/M visit.

CMS has also proposed a second modifier, currently called “MOD2,” for eligible practitioners participating in a Medicare Shared Savings Program Accountable Care Organization or the Long-term Enhanced ACO Design Model. That modifier would increase the associated E/M payment by 32%. CMS says its use would be voluntary and would not be limited only to beneficiaries assigned or aligned to the ACO.

These are proposals, not final billing instructions. The proposed rule was issued July 14, 2026, and the public-comment period closes September 14, 2026. Practices should continue billing under the 2026 rules until CMS publishes and implements final guidance.

What practices should do to keep billing the complexity payment

The packaging may change, but the underlying reason for the payment remains longitudinal care. Under current CMS guidance, the service must reflect one of two relationships:

• The practitioner serves as the continuing focal point for the patient’s overall health care; or
• The practitioner provides ongoing care for a single serious condition or a complex condition.

G2211 is not supported merely because a patient has several diagnoses or because an E/M visit took extra effort. The record and claims history should show that the practitioner has assumed—or intends to assume—ongoing responsibility for the patient’s care with consistency and continuity.

CMS does not require a special diagnosis or a separate documentation statement. However, the assessment, plan, follow-up, care coordination and overall record should make the longitudinal relationship clear. A short phrase inserted into every note will not cure a visit that does not meet the intent of the code.

For 2026, G2211 may be reported with office/outpatient E/M codes 99202–99205 and 99211–99215 and with home or residence E/M codes 99341, 99342, 99344, 99345 and 99347–99350. It is not separately payable to RHCs or FQHCs because it is bundled into their encounter-based payment, and it does not apply to inpatient, emergency department or nursing-facility E/M code families.

Practices also need to keep the modifier-25 rule straight. Medicare generally denies G2211 when the associated E/M service is reported with modifier 25. The exception is an E/M service performed on the same day by the same practitioner as an Annual Wellness Visit, vaccine administration or another Medicare Part B preventive service. Beginning in 2026, that exception also applies to qualifying home or residence E/M visits.

The potential financial impact

Under the July 2026 national non-facility Medicare RVU file for non-qualifying APM participants, G2211 represents approximately $17.37 before geographic adjustment. The following examples apply CMS’s proposed 16% formula to 2026 national non-facility E/M amounts solely to illustrate how the payment method could redistribute revenue.

For a 99212 service, the proposed 16% payment would be approximately $9.51, compared with the current G2211 illustration of $17.37—a difference of approximately -$7.86.

For a 99213 service, the proposed payment would be approximately $15.23, or about $2.14 less than the current flat-rate illustration.

For a 99214 service, the proposed payment would be approximately $21.70, or about $4.33 more than the current illustration.

For a 99215 service, the proposed payment would be approximately $30.78, or about $13.41 more than the current illustration.

This is a planning illustration, not a 2027 fee schedule. Actual reimbursement will depend on the final rule, the final modifier specifications, 2027 RVUs, the applicable conversion factor, geographic adjustments, site of service, APM status, payer policy and patient cost-sharing.

The lesson is straightforward: your E/M distribution will matter more. A practice with mostly 99213 visits could receive less complexity payment per eligible encounter, while a practice with mostly 99214 and 99215 visits could receive more. That is not permission to raise E/M levels. Every E/M code must continue to be selected based on supported medical decision-making or time.

For scale, consider a practice billing 500 eligible services per month. At the approximate current national non-facility amount of $17.37, the annual allowed amount is about $104,220. Using the proposed percentage method and the 2026 amounts above:

• If every visit were a 99213, the annual amount would be about $91,380, a decrease of approximately $12,840.
• If every visit were a 99214, the annual amount would be about $130,200, an increase of approximately $25,980.
• With a mix of 40% 99213, 55% 99214 and 5% 99215, the annual amount would be about $117,400, roughly $13,200 more than the current flat-rate illustration.

Those figures are gross allowed amounts, not guaranteed collections. Medicare Part B deductible and coinsurance rules apply, and Medicare Advantage and commercial payer policies may differ.

A practical readiness checklist

Medical practices should take the following steps before the final rule arrives:

1. Do not stop billing G2211 in 2026. The current code and current rules remain in effect.
2. Run a 12-month baseline report. Measure eligible E/M volume, G2211 utilization, payment rate, denial rate and code-level distribution by provider.
3. Audit for clinical support. Review whether notes and claim histories demonstrate ongoing responsibility, continuity and care planning—not simply diagnosis count.
4. Review modifier-25 edits. Confirm that billing staff and claim rules recognize the preventive-service exception and do not apply it more broadly.
5. Prepare your systems, but wait for final specifications. Ask the EHR, clearinghouse and billing software vendors how they will replace the G2211 claim line with the final modifier if CMS adopts the proposal.
6. Confirm ACO eligibility. Practices participating in the Shared Savings Program or LEAD Model should verify which practitioners and billing entities could qualify for the proposed 32% modifier.
7. Model the impact by E/M level. A single average dollar estimate can hide a material revenue shift. Model 99212 through 99215 separately and include home or residence visits when relevant.
8. Check every payer. Do not assume Medicare Advantage or commercial plans will adopt the same modifier, timing or reimbursement methodology.

The bottom line

G2211 is not simply an extra payment for a complicated patient. It recognizes the work and responsibility created by an ongoing practitioner-patient relationship. That standard is not going away. What may change in 2027 is how the service is reported and how much it pays.

Practices that understand their current utilization, tighten documentation and prepare their billing systems will be in the strongest position to protect both compliance and revenue. Practices that wait for the first denial in January will already be behind.

If your practice needs a G2211 utilization review, documentation assessment or a financial-impact analysis based on your actual E/M mix, contact Sunrise Services to request a consultation.

Sources

• CMS: CY 2027 Medicare Physician Fee Schedule Proposed Rule
• CMS: Frequently Asked Questions About G2211
• CMS: July 2026 Physician Fee Schedule RVU File