In May 2022, Cigna announced that it would begin requiring the submission of medical records for all claims billed with E/M codes 99212-99215 and a modifier 25 to support an additional separately billable service or procedure on the same date of service.
The original Cigna announcement indicated this new rule would go into effect on August 13, 2022, and instructed practices to send the medical records that support a separately identifiable E/M service was provided, along with “a cover sheet indicating the office notes support the use of modifier 25 appended to the E/M code”.
However, when Cigna made this announcement there was serious concerns voiced throughout the industry, including by the American Medical Association (AMA) and the California Medical Association (CMA). Cigna’s change in policy will undoubtedly create unnecessary administrative burden and cost for practices. Both the AMA and CMA reached out to Cigna regarding these concerns.
Subsequently, Cigna sent out a reimbursement policy update letter to practitioners indicating that there will be a “delay” in the implementation of the Modifier 25 record submission requirement.
Here is the content of the Cigna letter.
Re: Reimbursement policy update: Implementation delay for evaluation and management codes billed with modifier 25 and minor procedures
We recently sent a letter informing you about an update we planned to make regarding reimbursement for 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.
We are currently reevaluating this reimbursement policy change, which will delay implementation.
What this means
The Modifier 25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service reimbursement policy update will not go into effect on August 13, 2022, as originally scheduled.
We will communicate a new implementation date and details after our internal evaluation is complete.
This letter doesn’t mean that Cigna will not move forward with this requirement in the future, but it is being reevaluated. Practices should think about how they will implement this requirement if it goes into effect. For practices with questions on the policy update they can contact Cigna Customer Service directly at (800) 88Cigna (882-4462).
This type of policy announcement should also be a reminder for practices to ensure you are only coding for separately billable E/M services that meet coding and documentation requirements.
Understanding Modifier 25 Requirements
- Modifier 25 is defined as a significant, separately identifiable Evaluation and Management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service.
- It is used to report an E/M on the same day as a minor procedure when the separate/significant service provided is above and beyond the usual pre and/or post operative care associated with the procedure
- Modifier 25 can also be used to report an E/M on the same day as other services such as Preventive, Physicals or an AWV encounter when a patient has a “sick/injury” concern that is separately addressed at the same visit.
- In either circumstance the documentation must support the separate service was above and beyond the usual pre and/or post operative care or preventive service requirements.
- Defining a Minor Procedure
- Procedures with a zero or 10-day post op period
- Generally E/M services provided on the same day as a minor procedure are included as part of the service.
- The standard time involved in pre-service, intra-service and post-service care has been included in the calculation of the total wRVU’s established for minor procedures.
- Understanding Preventive Services (Physicals/AWV)
- Preventive services are usually Physicals and AWV type encounters.
- These are encounters where there is no patient “complaint” of a current injury, illness or condition.
- If a patient has a chronic condition that is evaluated as part of their preventive encounter, this does not necessarily support a separate E/M service. It is expected that the clinician will address chronic conditions during a preventive encounter. If the encounter is stable with no concerns or adjustments to the current care regimen, this does NOT qualify as a separately identifiable E/M service.
Article by Sheila Haynes, Coding & Compliance Manager