Cigna Delays Problematic Modifier 25 Policy
By Alisa Pierce

Cigna will delay its demanding requirement for physicians to submit additional documentation for routine, minor procedure claims after the Texas Medical Association, American Medical Association, and dozens of other medical organizations urged the payer to immediately rescind the policy in April. 

Signaling a win for organized medicine, Cigna announced via its modifier 25 policy outline that the insurer is reevaluating the mandate and that implementation has been delayed indefinitely.  

The insurer is “delaying the implementation of the modifier 25 policy … to ensure that modifier 25 is used appropriately and in alignment with national guidelines and industry standards,” according to a communication from Cigna that AMA shared with TMA. AMA added Cigna will communicate additional information after its internal evaluation is complete. 

The company had previously announced that, effective June 11, all claims billed with modifier 25 would be denied automatically unless accompanied by a full set of office notes that show a significant and separately identifiable service was performed. This policy would extend to procedures billed with evaluation and management (E/M) codes 99212-99215 and a minor procedure.  

That included 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.  

TMA, AMA, and more than 100 state, national, and specialty medical organizations expressed their shared concerns over the mandate. 

“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 in an April 18 letter. 

Cigna may implement the policy after the payer “can optimize the provider experience and perform additional provider education in partnership with key national medical associations,” the AMA communication said.  

TMA experts are monitoring possible changes in how payers process claims with modifier 25. Meanwhile, they 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 that the separate service was above and beyond the usual pre- and/or post- operative care or preventive service requirements.   

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

• Always append 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.