Cigna to require more documentation for claims that bill an E/M visit with a minor procedure    

Editor’s note (May 26, 2023): Cigna has delayed implementation of its modifier 25 policy change. 

Health insurer Cigna recently announced it will require more documentation for claims that bill for an evaluation and management (E/M) visit with CPT codes 99212-99215 and modifier 25, along with a minor procedure. Cigna will deny the E/M claim if the medical records do not support that a significant and separately identifiable service was performed in addition to the procedure. Minor procedures are those with a zero or 10-day post-operation period (the Centers for Medicare & Medicaid Services’ website includes a list of applicable codes).

Cigna's policy change comes despite opposition from the American Academy of Family Physicians (AAFP) and other major medical groups. It is scheduled to take effect in most states May 25 and then expand to California, Colorado, Kentucky, Ohio, and Texas on June 11.

When the policy takes effect, practices should submit documentation with a cover sheet indicating office notes support the use of modifier 25 appended to the E/M code. The following information must be included on a cover sheet:

• Physician or billing name,
• Physician Taxpayer Identification Number (TIN),
• Alternative Member Identification (AMI),
• Patient name,
• Date of service.

In addition to completing the cover sheet, practices should select the attachment indicator, which alerts Cigna’s claims processing that a submitted claim will have an attachment faxed or mailed on the same day. Then fax the office notes to 833-462-1360 or email them to modifier25medicalrecords@cigna.com.

Cigna delayed policy last year amid opposition 

Cigna first announced this new policy in May 2022. The AAFP opposed it and urged Cigna to rescind it, arguing that it would effectively penalize physicians for providing unscheduled care in an efficient way. Cigna delayed the policy last year but recently announced they were moving forward with it.

The AAFP, along with more than 100 national and state medical organizations and societies, has signed on to an American Medical Association letter urging Cigna to reconsider due to the policy’s negative impact on practice administrative costs and the additional administrative burden it will place on physician practices.  

Practices with questions or concerns can contact Cigna customer service at 800-882-4462. 

For more information on using modifier 25, see the FPM Getting Paid blog post “Seven quick tips for using modifier 25” or the FPM article “Understanding When to Use Modifier 25.”

— Brennan Cantrell, AAFP Commercial Health Insurance Strategist

Posted on May 11, 2023