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Revised Cigna Policy-A Concern for Physician Practices

What is Modifier 25?

Modifier 25 is a coding modifier used to indicate that a significant, separately identifiable evaluation and management (E/M) service was provided on the same day as another service or procedure. evised Cigna Policy for modifier 25 limits the use of this modifier in certain circumstances, such as when the E/M service is performed as part of a routine exam or is not separately identifiable from the other service or procedure.

Cigna’s Revised Policy is Unfavorable For Healthcare Providers:

The concerns that doctors may have with this updated policy may include the potential for reduced reimbursement for E/M services, increased administrative burden in determining when modifier 25 can be used, and possible negative effects on patient care if doctors are unable to bill for necessary E/M services. However, it is important to note that Cigna’s policy is designed to ensure that services are being billed accurately and appropriately, which ultimately benefits patients and helps to control healthcare costs.

Cigna Policy Revision Resumed:

CIGNA recently announced a change to their policy regarding the use of modifier 25 when billed with the E/M CPT codes 99212-99215 and a minor procedure. Beginning May 25, 2023, providers will be required to submit documentation to support the use of modifier 25. This change was initially announced in May 2022 and caused some concern among medical societies like The California Medical Association (CMA) who saw it as creating unnecessary administrative burden and compliance costs for physician practices. After advocacy efforts by these medical societies, Cigna announced a pause in implementation to reevaluate the policy. Unfortunately, Cigna recently announced that they will be moving forward with the same policy effective May 25, 2023.

Cigna originally notified providers of this policy in May of 2022, which was met with opposition from CMA. CMA sent a letter to Cigna outlining concerns with the policy, urging them to rescind it as it effectively penalized physicians who provided efficient, unscheduled care to Cigna enrollees. CMA expressed that the policy would result in significant administrative burden and compliance costs for physician practices, dis-incentivize physicians from providing unscheduled services, and waste healthcare dollars with duplicate requests. Furthermore, the policy lacked clarity, was inconsistent with industry standards and CMS guidance, and appeared to violate California law.

CMA Opposed Policy Revision:

CMA’s advocacy efforts resulted in Cigna announcing in July 2022 that they would pause implementation of the policy to reevaluate it. Unfortunately, Cigna recently announced they will be moving forward with essentially the same policy effective May 25, 2023, which CMA believes continues to pose a significant and unnecessary burden on physician practices and May even be inconsistent with California law. CMA is advocating for a more collaborative approach to identifying alternative cost containment methodologies that do not penalize physicians using the modifier appropriately, as this approach may prove more effective and less costly in the long term.

CMA, AMA and Other Societies

CMA, along with the American Medical Association and other state and specialty societies, is reaching out to Cigna regarding ongoing concerns with this policy.

While there is still a chance that Cigna will withdraw the policy, it is recommended that medical practices take steps now to prepare for the change. This includes training staff on the appropriate use of modifier 25, reviewing previous claims submitted with the modifier, creating a process for submitting documentation in a timely manner, and educating staff on E/M coding guidelines in case of denials.

It’s important to note that some medical societies believe there are alternative cost containment methodologies that could be explored instead of penalizing physicians who use the modifier appropriately. The American Medical Association (AMA) and other state and specialty societies are reaching out to Cigna to address their ongoing concerns with the policy.

As the policy currently stands, Cigna requires documentation for the E/M service to meet the requirements in the 1997 documentation guidelines for E/M services, even though those guidelines do not apply to office/other outpatient visits. This inconsistency has caused confusion among medical practitioners and may lead to denials of claims.

Ways for Medical Practices to Ensure Compliance with the New Policy on Modifier 25 Usage

To avoid these denials and ensure compliance with the new policy, medical practices should train their staff on the appropriate use of modifier 25 and the full descriptor, which contains details on when it is appropriate to unbundle an E/M visit. Additionally, they should review previous claims submitted with modifier 25 and provide additional training if necessary, create a process for submitting additional documentation in a timely manner, and educate staff on the CPT guidelines for office/other outpatient E/M services.

Preparing for Cigna’s Policy Change on Modifier 25 Usage in Medical Practices

Medical practices should be aware of the upcoming change to Cigna’s policy regarding modifier 25 and take steps to prepare for its implementation. While some medical societies continue to advocate for a more collaborative approach to cost containment, it is important to comply with the new policy to avoid denials and ensure efficient claims processing.

In summary, providers should be aware of the upcoming requirement to submit documentation for established patient E/M visits when unbundling them from a minor procedure with modifier 25. This change may cause some administrative burden and compliance costs, but preparation and education can help mitigate these issues. Medical societies continue to advocate for a more collaborative approach to cost containment that does not penalize physicians for providing efficient, unscheduled care.

I have attached the revised policy. Click to review.