The Cigna Group recently notified network providers that it will deny payment for Evaluation and Management (E/M) services reported with modifier 25 if records documenting a significant and separately identifiable service are not submitted with the claim. Modifier 25 records and bills for E/M service on the same day of another service or procedure when it is performed by the same physician or provider.

This triggered a contentious response from the American Medical Association (AMA) and more than 100 other provider trade associations who have taken issue with a new policy from Cigna regarding claims with modifier 25.

Evaluation and management (E/M) services represent a category of Current Procedural Terminology (CPT®) codes used for billing purposes. E&M coding involves use of CPT codes ranging from 99202 to 99499. Office visits, hospital visits, home services and preventive medicine services are considered E&M codes. Codes for procedures like surgeries, radiology and diagnostic tests, and certain treatment therapies are not considered evaluation and management services.

Current Procedural Terminology (CPT®) modifiers (also referred to as Level I modifiers) are used to supplement the information or adjust care descriptions to provide extra details concerning a procedure or service provided by a physician. Code modifiers help further describe a procedure code without changing its definition. Several of these modifiers have become topics of controversy between providers and payers.

Modifier 25 is used to facilitate billing of E/M services on the day of a procedure for which separate payment may be made. It is used to report a significant, separately identifiable E/M service by the same physician on the day of a procedure.

For example, modifier 25 may be used in the rare circumstance of an E/M service the day before a major operation and represents a significant, separately identifiable service; it likely would be associated with a different diagnosis (for example, evaluation of a cough that might affect the operation).

The Centers for Medicare & Medicaid Services (CMS) has identified the overuse and misuse of Current CPT® code modifier 25, and has taken regulatory action hoping to circumvent the problems it has identified. The 59 modifier is considered the most misused modifier by coders. It is normally used to indicate that two or more procedures were performed during the same visit to different sites on the body.

According to a report by  RevCycle Intelligence, the groups wrote in a letter to Cigna CEO David Cordani last week that the new policy is burdensome for providers even though they understand inappropriate use of modifier 25 should be prevented.

“We urge Cigna to reconsider this 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, and instead partner with our organizations on a collaborative educational initiative to ensure correct use of modifier 25,” they wrote in the letter.

The groups also said they questioned the standards or guidelines Cigna used to craft the new modifier 25 policy since the Current Procedural Terminology (CPT®) description 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. The CPT code set was developed by the AMA.

CMS and CPT guidelines also indicate that an E/M service reported with a modifier 25 does not need a different diagnosis than what was reported for the concurrent procedure, which Cigna misinterpreted in its current modifier 25 policy, according to the letter.

Failing to rescind the policy would result in an enormous amount of office notes being sent with claims, which not only burdens network providers but also the insurer.

“Indeed, Cigna previously advised medical societies that only a small percentage (i.e., 10 percent) of submitted documentation would be reviewed under this program,” the groups explained. “This troubling admission demonstrates Cigna’s awareness of the unmanageable volume of records in question and, more importantly, highlights the pointless administrative waste created by the policy.”

Adding to data submission burdens is the lack of an electronic standard for clinical record exchange, the letter continued.

“All of these concerns underscore that Cigna’s policy is extremely ill-timed and will further hamper health care professionals already grappling with clinician burnout, workforce shortages, recovery from the COVID-19 public health emergency, and rising practice expenses due to inflation,” the groups wrote.

The groups said they are willing to collaborate with Cigna to ensure the appropriate use of modifier 25, including doing targeted outreach and coding education. They also advised the insurer to limit documentation so that only network providers with consistent miscoding have to send office notes along with their claims.