Prepare for a tough new modifier 25 policy from Cigna in May

by Laura Evans, CPC on Mar 24, 2023
Get ready for a new prepayment review policy from Cigna for office E/M services billed with a minor procedure.
The payer first unveiled the policy last summer, then postponed its activation after protests from the AMA and some state medical societies that it would be too burdensome for practices and would impact patient care.
Now, however, Cigna appears poised to go live on May 25 with the restrictive policy.
Specifically, the payer states:
  • “We will require the submission of office notes with claims submitted with evaluation and management (E&M) Current Procedural Terminology (CPT) codes 99212, 99213, 99214, and 99215 and modifier 25 when a minor procedure is billed.
  • The E&M line will be denied if we do not receive documentation that supports that a significant and separately identifiable service was performed.
  • This update is effective for dates of service on or after May 25, 2023.”
To prepare for this change, practices will need to review provider documentation for office visits they bill with procedures, explains Edward Leone, CPC, CPC-P, CPMA, CRC, COSC, coding manager at Connecticut Orthopaedic Specialists in Hamden, Conn.
“When deciding whether modifier 25 should be appended, ask yourself the following questions,” he says:
  • Were the key components of a problem-oriented E/M service for the complaint or problem performed and documented?
  • Could the complaint or problem stand alone as a billable service?
Some physicians may be eager to bill such visits based solely on time using the new E/M guidelines, but many payers – including Medicare – are examining these claims closely for medical necessity, Leone says.
Leone, who has had success fighting for reimbursement of office visits billed with modifier 25 at his own practice, will share tools and guidance that have helped with this issue during the webinar, Modifier 25: Tested Strategies to Ensure Your Practice Bills Compliantly – and Gets Reimbursed, April 19, 2023, at 1 p.m. ET. More information available here.
Blog Tags: E/M services
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