Complex Pediatric Care-Coverage of HCPCS Add-On Code “G2211”
Impacted Plans: Medicaid and HIV- SNP
TO: All Providers
Dear MetroPlusHealth Provider,
Effective April 1, 2026, to align with the New York State Medicaid Guidelines, MetroPlus Health is allowing coverage and reimbursement of HCPCS add-on code “G2211” for eligible providers actively treating complex pediatric cases.
Clinical and Billing Criteria:
- Providers must document the medical complexity and ongoing care that justify the use of HCPCS code “G2211”, including how the visit aligns with a patient-centered plan of care.
- The visit complexity for HCPCS code “G2211” is related to the additional effort of providing longitudinal care. It is not based on specific diagnoses or the level of medical decision-making.
- HCPCS code “G2211” may not be reported for acute or routine care.
- Age Limitation: coverage of HCPCS code “G2211” is limited to Medicaid members from birth to 20 years of age.
- Frequency Limitation: claims billed more than once per week, per member will be denied.
- Please note, HCPCS code “G2211” needs to be treated as an add-on code and should not be reported independently.
- “G2211” must be billed in conjunction with an E/M procedure code, which may include preventative visit codes, on the same date of service.
- Place of Service (POS) Limitations: Reimbursement is allowable when billed with POS codes “02”, “10”, “11”, “19”, or “22 on professional claims.
If you have any questions regarding this memo, please contact MetroPlusHealth at 800.303.9626, or email Provider Relations at [email protected].
last updated: November 10, 2026