EM Coding Alert

Beware: The claims submission process may become more restrictive.

Commercial carrier Cigna has proposed a change to their payer policies for providers seeking reimbursement for same-day procedures and evaluation and management (E/M) encounters. While the change has been delayed, as of publication, understanding the implications is important for retrieving the money your providers have earned.

Know what Cigna proposed so you can avoid denials.

Go Deep on the Details

Cigna received multiple concerns from advocacy groups when the payer proposed lifting the pause in the implementation of its revamped modifier 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service) reimbursement policy. Experts warn the proposed policy could lead to unnecessary administrative burden and compliance costs for practices.

In response to the advocacy groups’ reactions, Cigna has decided to delay the policy implementation, as of May 23, 2023. According to the updated reimbursement policy on the payer’s website, “Cigna will continue to review for future implementation” (https://static. cigna.com/assets/chcp/secure/pdf/resourceLibrary/ clinReimPolsModifiers/Notifications/ Modifier_25_Significant_ Separately_Identifiable_Evaluation_and_Management.pdf).

Cigna’s proposed policy, which they have now delayed, would have required the submission of medical records with all established patient E/M claims submitted with CPT^® codes 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) and modifier 25 when the provider performs and bills for a minor procedure for the same encounter. Failure to submit records would have resulted in a denial of the E/M service.

Example: An established patient comes into your provider’s office for a follow-up appointment for management of their chronic obstructive pulmonary disease (COPD). During the visit, the patient reports new and worsening symptoms of shortness of breath, chest pain, and fatigue. The provider performs a comprehensive evaluation of these symptoms. Based on the evaluation, the provider determines that the patient needs an urgent bronchoscopy to further investigate the cause of the symptoms. The bronchoscopy is performed on the same day as the visit. This E/M service certainly warrants a separate charge due to its unrelated nature.

Currently, you can use established patient office visit codes 99212-99215 to report your provider’s services, depending on the level of medical decision making (MDM) your provider performed or time spent on the E/M service. You would also append modifier 25 to 99212-99215 to ensure payment when you bill them with the bronchoscopy code, such as 31622 (Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; diagnostic, with cell washing, when performed (separate procedure)).

Therefore, if the provider provided a level-two E/M service in the example above, you would report 99212-25 for the clinical assessment and 31622 for the bronchoscopy. If this policy goes into effect, you’d need to bolster documentation to justify the usage of the service.

Note Change to Modifier 25 Policy

Restrictions on how to send in supporting documentation would make the already arduous claims submission process even more cumbersome. According to Cigna’s proposed policy update, you would need to submit the required office notes via a dedicated fax number (833-462-1360) or via email to Modifier25MedicalRecords@Cigna.com.

Note: You should continue to submit claims electronically or via mail. If submitting electronically, verify you have selected the attachment indicator.

When submitting required office notes to Cigna via fax or encrypted email, include a cover sheet with the following information:

• Provider or billing name
• Provider taxpayer identification number (TIN)
• Alternate member identification (AMI)
• Patient name
• Date of service

Do this: If you send the documentation via email, safeguard protected health information (PHI) by encrypting the email — this essentially mixes up the contents of an email, so it becomes a puzzle that only you and the intended recipients have the key to solve.

Industry reactions to the policy have been mixed, with some believing they will increase practice costs and others saying they won’t. Although the cost of some encrypted email systems can reach into the thousands of dollars, there are systems with a yearly subscription to an email encryption service for as low as $99 for a single user, which does not add significant costs to the practice, notes Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, AAPC Fellow, of CRN Healthcare Solutions in Tinton Falls, New Jersey.

On the other hand, “This policy will impose an estimated cost of $3.29/per claim to produce the record and fax to Cigna, which will result in a net payment reduction … This is a complete waste of health care dollars and practice time that would be better spent providing care to patients,” said Robert E. Wailes, MD, president of the California Medical Association (CMA) in a letter to Cigna, urging the payer to rescind the policy.

Consider Options for Delayed Payments

Remember to mark your calendar when submitting these claims and documentation. If Cigna or any other payer fails to remit payment within the state’s mandated prompt payment timeframe, you can file a complaint to hold them accountable to prompt payment laws. Make sure you know what your state’s laws require.

Don’t let this possible policy change disincentivize your physicians from providing efficient, medically necessary (although unscheduled) care to Cigna enrollees. If providers are not too aggressive in billing an E/M with a minor procedure and provide clear documentation supporting the office visit as a significant and separately identifiable service, Cigna should reimburse accordingly. If they don’t, appeal.