Medicine Urges Cigna to Withdraw Far-Reaching Modifier 25 Policy
By Alisa Pierce

Demonstrating the far-reaching impact of a new Cigna policy, the Texas Medical Association joined organized medicine in collectively and vociferously calling on the payer to “immediately rescind” an onerous requirement for additional documentation for routine, minor procedure claims starting in June. 

TMA, the American Medical Association, and more than 100 state, national, and specialty medical organizations expressed their shared concerns in an April 18 letter over the mandate to submit office notes with all claims that include evaluation and management (E/M) services and modifier 25 when a minor procedure is billed.  

Cigna has said the policy is intended to reduce inappropriate use of the modifier. But medicine and others challenged that notion, citing the significant administrative burdens and costs that would result, as well as Cigna’s lack of appropriate data “demonstrating unexpectedly high use of the modifier or details of the underlying rationale.” 

“We urge Cigna to reconsider this policy due to its negative impact on practice administrative costs and burdens across medical specialties and geographic regions, as well as its potential negative effect on patients, and instead partner with our organizations on a collaborative educational initiative to ensure correct use of modifier 25,” the groups wrote. 

Rather than penalizing all physicians, they offered to collaborate with Cigna on: 

• Targeted outreach to selectively engage network physicians with unexpected coding patterns in follow-up education and dialogue;  
• Educational and training initiatives to encourage correct coding; and 
• Limiting the documentation requirement to those practices with consistent patterns of E/M misreporting. 

Barring any changes, physicians will be required to submit additional documentation starting June 11. 

E/M services provided on the same day as a minor procedure (such as those with a zero or 10-day post-operation period) typically have been included as part of the service. Starting June 11, however, Cigna will start requiring separate supporting documentation every time a physician bills for that minor procedure using modifier 25.   

That includes supplying medical records and “a cover sheet indicating the office notes support the use of modifier 25 appended to the E/M code,” according to Cigna’s first announcement of the policy last year. The claim will be denied if a physician fails to show a significant and separately identifiable service was performed.  

Medicine won a delay of the policy that was supposed to start Aug. 13, 2022, after AMA and the California Medical Association voiced several concerns including a likely increase in administrative burden and cost for practices due to duplicate requests and a lack of clarity on which Cigna health plans would be impacted.  

Medicine also expressed these challenges would not only harm patients’ experience, but also disincentivize physicians from providing unscheduled services – a concern emphasized in April’s letter. 

“Cigna’s policy creates a disincentive for physicians and other health care professionals to provide unscheduled services, which may force patients to schedule multiple visits (with additional co-payments) to receive necessary treatment,” the letter said. 

As most practices use modifier 25 throughout the day, the additional documentation requirement could force practices to send several medical records daily, potentially contributing to physician burnout, says Odessa allergist Vivek Rao, MD.  

“So many specialties use 25 modifiers on a frequent basis, and this update is only going to delay processing claims,” he said. “My fear is that this is going to create a backlog where practices must wait to get paid for providing care to patients. Then, physicians are going to have to make some difficult business decisions, like not accepting new patients.”  

TMA will meet with each major insurance company in the coming months to discuss this and other administrative burdens and payment delays that impact physicians’ ability to care for their patients.  

Meanwhile, TMA experts recommend physicians familiarize themselves with modifier 25, which is used: 

• To indicate that on the day a procedure was performed, the patient’s condition required a significant, separately identifiable E/M service (such as in the case of a new or distinct problem) beyond other services provided by a physician or health care professional;  
• To report an E/M service 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; and   
• To report an E/M service on the same day as other services such as preventive care, physicals, or an annual wellness visit when a patient has a “sick/injury” concern that is separately addressed at the same visit.  

Documentation must support the separate service was above and beyond the usual pre- and/or post- operative care or preventive service requirements.  

TMA staff say practices can ensure they are documenting modifier 25 claims correctly by taking these steps:  

• Always append the modifier 25 to the E/M code (reported to the appropriate level), never to the procedure code.  
• Don’t report a separate E/M service for a planned procedure.     
• If a new problem needs only a cursory review, it will not qualify as a separate E/M service.  

Have questions or concerns? Call TMA’s billing and coding hotline at (512) 370-1414 to speak directly with one of TMA’s certified coders or visit TMA’s Reimbursement, Review, and Resolution Service for more information.