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Cigna revises modifier 25 policy, targets unbundled office visits

Cigna’s plan for unbundled office visits is likely to increase your paperwork and and slow reimbursement.
In reimbursement policy M25, Cigna warns that, effective Aug. 13, it will deny clarims for 99212-99215 that are submitted with modifier 25 unless documentation for the claim supports the medical necessity of the separate visit. The policy also instructs practices to send the notes with “a cover sheet indicating the office notes supports the use of modifier 25 appended to the E/M code.”
Given the update, your practice should prepare to submit the documentation for an established patient E/M visit when you unbundle the visit from a minor procedure with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).
To date, at least two medical societies are pushing back against the move, and there remains a chance that Cigna will withdraw the policy.
But you should take the following steps now, just in case:
  1. Train treating practitioners, coding and billing staff on modifier 25’s full descriptor. The full descriptor contains details that explain when it is – and is not – appropriate to unbundle an E/M visit.
  2. Review a few notes for claims that were submitted with modifier 25 and provide additional training if necessary.
  3. Create a process for submitting the additional documentation in a timely manner.
  4. Make sure staff who handle appeals have a firm understanding of the CPT guidelines for office/other outpatient E/M services.
Keep a close eye on denials and be prepared to educate Cigna’s staff on E/M coding guidelines if Cigna does enact the policy. The payer's policy currently states that modifier 25 is appropriate when documentation for the E/M service meets the requirements in the 1997 documentation guidelines for E/M services, even though those guidelines do not apply to office/other outpatient visits.
According to a letter from Cigna that was posted by the California Medical Association (CMA), the new policy is the result of a “recent review.” The letter also instructs providers to send the documentation to a dedicated fax line and continue to submit claims electronically. In a June 6 blog post about the new policy, the CMA announced that it and the AMA have reached out to Cigna with “concerns” about the policy. Keep an eye on the Part B News Blog for updates.

Modifier 25 – Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or be beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform major surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.
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