Urology Coding Alert

Remember to appeal when warranted.

If your urologist sees patients with Cigna insurance, you’ll want to get familiar with the payer’s updated policies for seeking reimbursement on same-day procedures and evaluation and management (E/M) encounters.

Read on to learn more about the requirements set forth in the updated policy and key considerations to help your practice avoid increased denials. After reading this article, review three myths that might be hindering your modifier 25 claim acceptance rate in “Break Your Modifier 25 Bad Habits to Improve Claim Acceptance” on page 6 of this issue of Urology Coding Alert.

Delve Into the Details

Despite advocacy groups voicing multiple concerns, one major payer is lifting the pause in the implementation of its revamped modifier 25 reimbursement policy, which experts warns could lead to unnecessary administrative burden and compliance cost for practices.

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 the provider performs and bills for a minor procedure for the same encounter. Failure to submit records will result in a denial of the E/M service.

Example: An established patient comes to your office for a Lupron injection. The patient also mentions pain during urination. The urologist sees the patient prior to the injection and performs an E/M service because they suspect an active urinary tract infection (UTI). The physician also performs a urinalysis and prescribes an antibiotic. This E/M service certainly warrants a separate charge due to its unrelated nature.

You can use established patient office visit codes 99212-99215 to report your urologist’s services, depending on the level of medical decision making (MDM) your urologist performed or time spent on the E/M service. You would append modifier 25 to 99212-99215 to ensure payment when you bill them with 96402 (Chemotherapy administration, subcutaneous or intramuscular; hormonal anti-neoplastic).

Therefore, if the urologist provided a level-two E/M service in the example above, report 99212-25 for the clinical assessment, 96402 for the Lupron administration, and J9217 (Leuprolide acetate (for depot suspension), 7.5 mg) for the drug.

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 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.

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, or any other payer, 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.