In this episode of Practice Perfect, Jennifer McNamara dives into the CMS G2211 complexity add-on code—specifically how it applies (or doesn’t!) to specialty practices. Whether you’re in orthopedics, ENT, plastics, or any other niche, we’ll unpack CMS’s intent, share real-world scenarios, and give you actionable tips to document and bill confidently.

• What is G2211?
  A quick refresher on the 2024 complexity add-on for longitudinal care and complex decision-making.

• Specialty Scenarios
  How CMS’s guidance plays out in orthopedics vs. general surgery vs. other specialties.

• Documentation Must-Haves
  What language drives approval—and what red flags to avoid.

• Billing Best Practices
  Reminder: as of 2025, you can bill G2211 with an AWV using modifier 25—here’s how to do it right.

In this episode, we break down two commonly misunderstood terms in healthcare coverage: "Statutorily Excluded" and "Not Medically Necessary."

While they may sound similar, these distinctions have major implications for providers, payers, and—most importantly—patients.

We explore how these classifications affect insurance claims, appeal rights, provider obligations, and patient financial responsibility. Whether you're a healthcare administrator, clinician, or just navigating your own care, understanding this difference can help you advocate more effectively within the system.

• ✅ What "statutorily excluded" means under federal healthcare programs like Medicare

• ✅ How "not medically necessary" determinations are made

• ✅ Why the distinction affects patient billing and appeals

• ✅ Key compliance and documentation tips for healthcare providers

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• 1. Statutorily Excluded: Services never covered by law, regardless of medical need (e.g., cosmetic surgery under Medicare).

  2. Not Medically Necessary: Services denied based on clinical judgment or guidelines—even if technically covered.

  3. Appeal Rights: Patients typically cannot appeal statutory exclusions but can appeal denials based on medical necessity.

  4. Documentation Matters: Accurate clinical notes can be the difference between a denied and an approved claim.

  5. Proactive Communication: Providers should notify patients in advance using tools like ABNs (Advance Beneficiary Notices).

     
     

     
     

     Advance Beneficiary Notice (ABN) Guide

     
     

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Whether you’re a coder hunting for the right CPT, a tumor registrar assembling a perfect abstract, or a practice manager double‑checking documentation, that pathology report is gold— if you know how to mine it. In this episode Jennifer breaks down her go‑to process for turning dense, microscopic jargon into clean, billable data that tells the patient’s full story.

In this conversation you’ll learn:

• How to navigate the four must‑read sections of every path report (and why the microscopic description isn’t always the MVP).

• Pro tips for translating diagnostic phrases into precise ICD‑10‑CM codes—without over‑coding malignancy.

• When a single tumor can drive multiple CPTs (and when bundling rules shut that down).

• Common abstracting traps—margin language, laterality gaps, and “NOS” pitfalls—and how to fix them before they hit the claim.

• Simple query templates that get pathologists to clarify size, grade, or margins without slowing the lab down.

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