AAFP, Others Denounce Cigna’s Modifier 25 Policy Change

Indiscriminate Application of Flawed Policy Harms Physicians, Patients

(Editor’s Note: Cigna announced on May 22 that it would again “delay the implementation to require the submission of documentation to support the use of modifier 25 when billed with E/M CPT® codes 99212 – 99215 and a minor procedure. Cigna will continue to review for future implementation.”)

May 3, 2023, Cindy Borgmeyer — A change in claims payment policy Cigna Healthcare says it will begin implementing next month flies in the face of the following statement on the company’s website: “We take on the administrative burden so you can focus on getting patients the care they need, and get paid in a timely manner.”

In 2017, for example, the AAFP strongly advocated against an Anthem policy that would have reduced payment for E/M services by 50 percent when billed with modifier 25. After the insurer backed away from that proposal but still planned a 25% cut, the Academy, the AMA and other medical specialty groups continued to protest the move, eventually securing a favorable outcome.

It’s important for members to know that the Academy regularly meets with national payers and participates in coalitions to advocate for policies that reduce physicians’ administrative burden, said Stacey Bartell, M.D., AAFP medical director for career and practice. Similarly, the AAFP collaborates with state chapters to address regional policies. At the federal level, she added, the AAFP advocates for legislation and regulatory policy that eases administrative complexity.

In this latest instance, the AAFP noted that Cigna’s announcement indicated the new policy was the “result of a recent review” but failed to reveal any findings that would merit such a change. The Academy called for “more targeted approaches that are based on valid data and updated as behavior changes over time rather than penalizing all physicians.” Specifically, the AAFP suggested that Cigna “identify physician outliers and implement policies that ensure the correct use of modifier -25 for those physicians and/or practices.”

Indiscriminate application of such policies, the AAFP warned, “add to the administrative burden faced by physicians and their staff and drain practice resources to care for patients.”

AMA-led Outreach Details Same Concerns

After reiterating this message during its annual meeting with Cigna, the AAFP also signed on to an April 18 AMA letter that called on the insurer to immediately rescind the 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.” The letter was co-signed by more than 100 national and state medical associations.

Like the AAFP, the groups expressed doubts about the basis for Cigna’s action, especially the assertion that “‘evidence-based medicine, professional society recommendations, Centers for Medicare & Medicaid Services (CMS) guidance, industry standards, and/[or] . . . other existing policies’” played a role in the insurer’s decision.

“We question what standards or guidelines Cigna consulted in initiating this policy change,” the groups wrote, “as the CPT description clearly states that modifier 25 enables reporting of a significant, separately identifiable E/M service by the same physician or other health care professional on the same day of a procedure or other service. The clinical vignettes included in a March 2023 CPT Assistant article illustrate the strong clinical basis for the use of modifier 25 to support effective and efficient care.”

Furthermore, the groups noted in their letter, “By facilitating the provision of unscheduled, medically necessary care, modifier 25 supports prompt diagnosis and streamlined treatment — which in turn promotes high-value, high-quality, and patient-centric care.”

Policy Would Exacerbate Administrative Burden

Particularly problematic for both physicians and Cigna, according to the letter, is that compliance with the policy requiring clinical documentation for all such claims means that “physicians and other providers will be forced to submit an enormous number of office notes, and Cigna will be deluged with medical records” — only about 10% of which would be reviewed under the program, the insurer had previously stated.

“This is going to be a heavy burden on practices that already don’t have enough staff to support the work,” said Bartell. “Some practices will wait for the rejection to submit a copy of the progress notes, while others will need to try to build stopgaps into their billing systems, and notes will need to be manually submitted. Either way, this will lead to a tremendous increase in administrative work and probable delay in payment.”

According to the AMA letter, the burden this process would pose for physicians is further complicated by the methods Cigna has designated for submission of the required documentation (a point the AAFP also raised in its letter) — that is, either by fax or via an email address created for this purpose. However, Cigna failed to address the need to secure protected health information in its announcement, placing both health care professionals and Cigna at risk of HIPAA noncompliance.

Privacy and Security of Patient Data Imperiled

The costs associated with implementing and maintaining a secure email system to comply with this requirement would impose another undue burden on physician practices, said the letter, calling for that expense to be borne by Cigna.

“Because there will not be a secure portal for submission, we anticipate this will lead to further delays in payment, as processing all of these submissions manually could require a significant amount of time,” Bartell said.

Overall, she concluded, “We anticipate this may discourage the correct use of these codes for services, therefore requiring that the patient return in the future for more services, leading to a delay in care and reduced access in an already overburdened system.”

The letter concluded with an offer to partner with Cigna on a collaborative educational initiative to ensure correct use of modifier 25 without unfairly punishing the majority of physicians and other health care professionals who code appropriately. Elements of such an initiative should include selective engagement with physicians and other health care professionals who have unexpected coding patterns, education on correct coding practices and, if needed, documentation requirements limited to those who show consistent patterns of miscoding.