Ophthalmology and Optometry Coding Alert

And bust three myths to up your Modifier 25 billing game.

Get ready to jump through a few more hoops to submit the documentation for certain modifier 25 claims come May. Despite advocacy groups voicing multiple concerns, one major payer is lifting the pause in the implementation of its revamped modifier 25 reimbursement policy, which will result in a significant unnecessary administrative burden and compliance cost to practices.

Delve into the details: Cigna is moving forward with its policy to require the submission of medical records with all established patient evaluation and management (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 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service) when a minor procedure is also coded and billed. Failure to submit records will result in a denial of the E/M service.

Read on to learn more about the requirements set forth in the updated policy and key considerations to keep your practice in the clear. We’ll wrap things up by reviewing three myths that might be hindering your modifier 25 claim acceptance rate to increase your likelihood of success and proper payment.

Prepare for Changes to Cigna’s Modifier 25 Policy

Restrictions on how to send in supporting documentation will make the already arduous claims submission process even more cumbersome. Starting May 25, 2023, you must 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 the attachment indicator is selected.

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.

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.

“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.

Don’t Stand for Delayed Payment

Remember to mark your calendar when submitting these claims and documentation. If Cigna fails to remit payment within the state’s mandated prompt payment time frame, 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 policy disincentivize your physicians from providing efficient, medically necessary, although unscheduled, care to Cigna enrollees. As long as 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.

Ditch These Coding Habits to Diminish Denial Distress

Even before this policy, getting modifier 25 claims paid was tricky. For pointers on how to avoid common pitfalls, read on. Bust these three myths and be one step closer to receiving rightful reimbursement.

Myth 1: Always append 25 for a minor procedure plus E/M.

All billable minor procedures (0-day or 10-day global period) already include an inherent small E/M component to gauge the patient’s overall health and the medical appropriateness of the service. Since the decision to perform a minor procedure is included in the payment — the relative value unit (RVU) includes pre-service work, intra-service time, and post-procedure time — an E/M service should not be reported separately.

When your eye care providers address a problem at the time of another service/procedure and the patient’s condition requires work above and beyond the other service provided or the usual care associated with the procedure performed, you should report the separate E/M with modifier 25 appended to get paid for both services.

Before you go reaching for modifier 25, make sure you’re using it because a minor procedure or other service and a separate and significant E/M service were performed:

• on the same patient;
• by the same physician;
• on the same date.

The key is recognizing when the additional work is “significant” and, therefore, additionally billable.

Myth 2: Submit claims with different diagnosis codes.

Different diagnosis codes are unnecessary; in some cases, the diagnosis code for the E/M and procedure codes will be the same. Claim success hinges on the E/M service being separate and significant, the documentation must substantiate this, and the physician’s work must be medically necessary.

Typically, if the E/M service is unrelated to the minor procedure (i.e., for a different concern/complaint, a condition in the fellow eye) or occurs due to exacerbation of an existing condition or other change in the patient’s status, the E/M service may be reported separately if it is independently supported by documentation.

Myth 3: Physical separation of documentation is required.

While you don’t need separate notes, physically separating the documentation for the E/M service from documentation for the other same-day procedure or service may help. What is necessary is having a medical record that demonstrates the necessity of and justification for the services performed. Payment hinges on the provider appropriately and sufficiently documenting both the medically necessary E/M service and the minor procedure/other service in the patient’s office note to support the claim for these services.

Tip: Make sure your providers show their extra cognitive work, as it will serve a critical role when the payer reviews the claim.