Medical Groups Voice Concern Over Payer's New Coding Policy

More than 100 medical associations have taken issue with a new policy from Cigna regarding claims coded with modifier -25.

Cigna is coming under fire for its new policy requiring submission of office notes with all claims including evaluation and management (E/M) codes 99212, 99213, 99214, and 99215 and modifier -25 when a minor procedure is billed.

Cigna says it will deny payment for these E/M services reported with modifier -25 if records documenting a significant and separately identifiable service are not submitted with the claim, and medical groups were quick to respond.  

For background, the revenue cycle coding staff report modifier -25 for E/M services on the same day of another service or procedure when it is performed by the same physician or provider.

The medical groups, including the American Medical Association, wrote in a letter to Cigna stating that the new policy is burdensome for providers and could negatively affect patients.

“Our organizations are alarmed by the significant administrative burdens and costs for health care professionals— and Cigna—that will result from implementation of this policy. By bluntly requiring clinical documentation for all claims for an E/M service reported with modifier 25, physicians and other providers will be forced to submit an enormous number of office notes, and Cigna will be deluged with medical records,” the letter said.

The groups are urging Cigna to reconsider this policy not only due to administrative burden, but because of its potential negative effect on patients, the letter said. Instead, the groups say Cigna should partner with organizations on a collaborative educational initiative to ensure correct use of modifier -25.

The groups also questioned the guidelines Cigna used to craft the new modifier -25 policy since the CPT code description "clearly states that modifier -25 enables reporting of a significant, separately identifiable E/M service by the same physician or other healthcare professional on the same day of a procedure or other service."

This latest update just adds to the already strained provider/payer relationship.

Unlike Medicare, which has standard, heavily documented rationales and processes for denials, appeals, and audits, almost anything goes when it comes to commercial payers like Cigna. Each payer organization will have different rules and processes, and payers’ manuals and bulletins aren’t always easy to locate.

“For us, it's really about new policy changes that they try to impose throughout the year and in the mid-contract period,” Patrick Wall, vice president of revenue cycle at St. Joseph's Candler, previously told HealthLeaders.

Even when policy changes spring up out of seemly nowhere, revenue cycle leaders have agreed that sometimes the administrative burden alone is too much. For example, BCBS also recently made a substantial increase in the number of medical records it requests to pay a claim.

All this back and forth means that staying compliant with payers has been, and will continue to be, a burden on the revenue cycle workforce. With already strained staff it can be hard to find extra hands, and money, to keep up with these payers.