- Key Takeaways
- Effective May 25, 2023, Cigna requires progress notes to be attached to any claim billing outpatient E&M codes 99212 through 99215 with Modifier 25 alongside a minor procedure — missing notes result in automatic denial.
- Modifier 25 indicates a separately identifiable E&M service was performed on the same day as a procedure — documentation must support both the procedure and the E&M as independent clinical encounters.
- Anthem made a similar Modifier 25 policy change on March 1, 2019 — practices that did not update workflows then are likely making the same documentation error with Cigna now.
- The AMA and 100+ physician organizations formally objected to Cigna’s policy citing negative impacts on administrative burden and patient access — the policy was not rescinded and remains in effect.
- Modifier 25 policy requirements vary by payer — practices must verify each major commercial payer’s documentation attachment rules before submitting E&M claims with procedures on the same date.
On May 25, 2023, Cigna released a new policy pertaining to Modifier 25 when billed on an Evaluation and Management (E/M) when a minor procedure is performed.
This new policy requires progress notes to be submitted when claims are billed as established outpatient E/M codes 99212-99215 only with modifier 25 when a minor procedure is performed.
You may be asking yourself…
What will happen if my office fails to attach the patient’s progress note?
The answer: Your claim will be denied.
Cigna is not the first insurance company to make changes to its Modifier 25 policy. On March 1, 2019, Anthem released its own policy stating that Anthem may deny the E/M service with a modifier 25 billed on the day of a related procedure when there is a recent service or procedure for the same or similar diagnosis on record.
While the American Medical Association (AMA) and more than 100 other physician and health care professional organizations submitted a letter to Cigna urging the insurer to “immediately rescind” siting the policy holds a “negative impact on practice administrative costs and burdens across medical specialties and geographic regions, as well as its potential negative effect on patients.”
They suggested that Cigna should, instead, work with the AMA along with state medical and national specialty societies “on a collaborative educational initiative to ensure the correct use of modifier 25.”
- Neolytix • Medical Billing
Medical Billing
How should your office prepare for this impending change?
- Don’t view the change as a burden but as an opportunity to utilize the template functions of your Electronic Health Record (EHR).
- Create a template for your practice specialty, ensuring an E/M and procedure visit.
- Within the template, there should be prompts to promote clear documentation for medical necessity.
- Initiate an office process for ensuring that a progress note is attached to claims for your Cigna patients when an E/M visit for established patients only requires a minor procedure.
Conclusion
Stay tuned for additional updates on impending changes. Should you have any concerns or queries, please contact us directly. At Neolytix, we are always ready to assist your practice with medical billing, coding, revenue cycle management, and other cost and revenue-associated services.
Our medical billing services are 100% HIPAA-compliant and provided by a certified team of professionals. Likewise, our medical credentialing services are fast, efficient, and organized according to rigorous workflow management procedures.
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