Cigna Delays Plan Requiring Medical Records With Modifier 25

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Cigna Delays Plan Requiring Medical Records With Modifier 25

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Modifier 25

UPDATE: Cigna has delayed the requirement described below, and it will no longer take effect on May 25. The company has not yet indicated when it will go into place, so keep an eye on the Healthcare Training Leader website for more information as this story develops.

When you perform a minor procedure along with an E/M service, you typically append modifier 25 to the E/M code, submit the claim, and move on. Starting next month, however, you’ll have another added layer of difficulty when you submit these claims to Cigna.

To continue collecting for your modifier 25 claims, it’s essential to know exactly what will be required of you when the new policy takes hold.

Cigna Plans to Deny Modifier 25 Claims Without Documentation in May

Effective May 25, 2023, Cigna will begin denying E/M claims with modifier 25 when billed with a minor procedure, unless you submit office notes to support the significant and separately identifiable E/M service you’re submitting.

Cigna originally tried to roll out this policy a year ago, but after significant pushback, the payer said it would reevaluate that policy rather than implementing it in 2022. But clearly that reevaluation is complete, with Cigna issuing its updated policy last month.

In black and white: The policy states, “Cigna requires the submission of office notes with claims submitted with E/M CPT codes 99212, 99213, 99214 and 99215, and modifier 25 when billed with a minor procedure. The E/M line will be denied if Cigna does not receive adequate documentation to support that a significant and separately identifiable service was performed. The documentation should be submitted with a cover sheet indicating the office notes supports the use of modifier 25 appended to the E/M code.”

Keep in mind that although the policy starts May 25 in most states, there may be different dates in other locations. For instance, the policy doesn’t start until June 11 in Texas, so check with your Cigna representatives to see when it starts in your state.

Only Approved Vendors Can Electronically Upload Records

Adding a wrinkle to this already complicated situation is the fact that Cigna won’t allow you to upload your documentation electronically unless you are an approved vendor. Otherwise, you must:

  • Fax your records
  • Email your records
  • Send your records through the mail

Many practices believe that this disjunct submission strategy will cause claims to be separated from the associated medical records, leading to mismatched documentation and unnecessary denials.

Ask your Cigna representatives how you should be submitting your documentation and what type of information you should add to these submissions to ensure your records get matched up with your claims in a timely manner.

How to Identify Your Significant, Separately Identifiable Claims

Other than adding the burdensome step of submitting your medical records with your claims, Cigna’s policy isn’t particularly different from how you’ve been utilizing modifier 25 in the past. This modifier has always been appended to E/M claims when a significant, separately identifiable procedure is performed. However, the new policy makes it a good time for a refresher on what actually constitutes a claim that meets these criteria.

Significant: The E/M service should be significant and not cursory. It should include more than the preservice work involved in performing the procedure. For instance, if you explain an injection to a patient and then administer the injection, you haven’t performed a significant E/M service. That explanation would be included in the payment for your injection procedure.

Separately identifiable: Your E/M documentation should be able to stand on its own when it’s completely separated from your procedure documentation. There should be no overlap in the work associated with the E/M service and that attached to the actual procedure.  If you cannot separate out and lift your E/M documentation out of your medical record and leave behind enough documentation to support the procedure, then you can’t report both.

Several medical associations have responded to Cigna’s upcoming requirement and vowed to fight it, arguing that it puts an unnecessary burden on medical practices. Keep an eye on this space as Training Leader shares updates as they arise.

To get more on how to appropriately apply modifier 25 and other E/M modifiers, check out Kim Huey’s 60-minute online training session. This step-by-step webinar will provide you with clear step by step instruction on how to ensure you are paid for more of the services and that your claims are correct, supported and audit-proof.


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