Cigna’s Policy on Modifier 25: Key Points and Guidelines

As a healthcare practice or provider working with Cigna insurance, staying up-to-date with their latest policies and requirements is vital. You need a team of staff who regularly check for updates and clarifications from Cigna so you can adjust your billing and administrative processes accordingly and remain compliant with insurance company requirements, and avoid billing errors or claim denials.

One such major change in Cigna’s modifier 25 policy update. Adhering to this policy is crucial in protecting your practice’s financial well-being and ensuring smooth interactions with this prominent insurance provider.

What You Need to Know About Cigna’s Modifier 25 Changes

Medical billing is already complex, and the new Cigna modifier 25 policy adds another layer of burden to medical practices. It’s wise to get a head start and learn everything you can about Cigna billing guidelines before its full implementation.

Cigna Modifier 25 Policy 2023: Delayed Implementation

In a letter sent to Cigna on April 18, 2023, the American Medical Association (AMA) and more than 100 other medical societies strongly opposed the Cigna modifier 25 policy update. 

Thanks to their collective effort, the May 25, 2023, implementation date did not go into effect as planned. Originally scheduled for August 2022, this is the second time Cigna has had to move its new policy’s implementation after receiving strong pushback from impacted groups. 

While Cigna has yet to provide a new date, the insurer is determined to introduce changes to its reimbursement policy and hinted at rolling out revisions after re-evaluation. 

That means submitting claims to Cigna for a minor procedure with an E/M service could become more challenging in the future. Whereas the current process only involves adding modifier 25 to the E/M code before claim submission, the new policy might introduce additional steps. To continue collecting modifier 25 claims, you must stay informed about the requirements once the new Cigna policy takes effect. 

Expect Stricter Guidelines

Should it have been fully implemented, the Cigna modifier 25 policy update will have denied E/M claims with modifier 25 when billed as part of a minor procedure unless you provide office notes supporting the significant and separately identifiable E/M service.

The policy states, “Cigna requires office notes for claims with E/M CPT codes 99212, 99213, 99214, and 99215, along with modifier 25 when billed with a minor procedure.  If you fail to submit adequate documentation proving you’ve performed a significant and separately identifiable service, Cigna could deny the E/M line. The documentation must include a cover sheet indicating that the notes support the use of modifier 25 appended to the E/M code.”

Furthermore, the documentation must adhere to the appropriate documentation guidelines. The insurer has emphasized that the E/M services rendered must meet the criteria outlined in the current CPT® E/M guidelines for code section 99202 – 99215 and the 1997 CMS documentation guidelines, as stated in their reimbursement policy for modifier 25.

A Guide to Identifying Significant, Separately Identifiable Claims

Besides submitting your medical records with your claims, Cigna’s policy is similar to how you’ve used modifier 25 before. You may already know that this modifier is added to E/M claims when you perform a significant and separate procedure. Now, it’s a good time to refresh your understanding of what qualifies as a claim meeting these criteria.

• Significant Claims

When we say “significant,” we mean the E/M service should be more than just a quick overview. It should involve more than just the essential work needed for the procedure. For example, if you explain an injection to a patient and then give the injection, that alone doesn’t count as a significant E/M service. The explanation is already included in the payment for the injection procedure.

So, before using modifier 25, ensure the E/M service meets the requirements, and remember to submit your medical records per Cigna’s policy.

• Separately Identifiable Claims

You must ensure that your evaluation and management (E/M) documentation can stand alone without relying on your procedure documentation. The work done for the E/M service should be distinct from the work done for the actual procedure. You cannot bill for both services if you can’t separate the E/M documentation from your medical records and still have enough documentation to support the procedure.

Stay updated on Cigna’s policies and guidelines related to Modifier 25 for 2023 to navigate this change effectively. Your proactive approach will be vital in adapting to policy adjustments. Embrace this chance to improve your practice and the positive changes that lie ahead.

This article serves solely for educational purposes. Refer to the websites below if you want further information regarding the updates on Cigna’s modifier 25 policy:

✔ For more references on Cigna’s billing guidelines, refer here:

https://static.cigna.com/assets/chcp/resourceLibrary/coveragePolicies/policyUpdates/coveragePoliciesLatestUpdatesMarch2023.html.

✔ Read about Cigna’s modifier 25 policy and how it burdens healthcare providers:

https://www.aafp.org/news/practice-professional-issues/cigna-modifier-25-policy.html

Getting Ready for the Changes Can Be Easier With 5 Star Billing Services

Developing the proper support and preparation will help your practice meet the updated modifier 25 standards. As medical billing evolves, this step is crucial. If you want the best way to stay ahead of industry changes and maximize revenue opportunities, partner with an expert medical billing company.

At 5 Star Billing Company, we have a proven track record in helping practices adapt to billing changes. Our team of skilled professionals handles your claims efficiently. Additionally, we provide valuable guidance on compliance and best practices to prevent issues in the future.

Don’t hesitate to contact 5 Star Billing’s revenue cycle management team to kickstart the process. With our expertise and support, you can confidently face Cigna’s policy changes and updates, knowing that your practice’s financial health is in capable hands. Let us help you thrive in the face of these modifications by scheduling a call TODAY!