Urology Coding Alert

Answer: You are correct that Cigna has sent updated guidance since Urology Coding Alert Vol. 25, No. 6 went to print with the news of the payer’s new modifier 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service) policy.

On May 23, 2023, Cigna updated the policy with this statement: “Cigna will 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.”

Background: In May 2022, Cigna first notified providers that in August 2022 it would begin requiring the submission of medical records with all evaluation and management (E/M) claims submitted using established patient office/ outpatient codes with CPT^® codes 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient …) when provider bills a minor procedure. As a result of advocacy efforts from many groups, such as the American Medical Association (AMA) and other state and medical specialty societies, Cigna announced in July 2022 it was pausing implementation to reevaluate the policy.

On March 13, 2023, Cigna then released a revised policy to reinstate the documentation requirement with E/M visits. The payer had planned to move forward with policy to require the submission of medical records with all established patient (99212-99215) E/M claims submitted 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. The original plan, set to take effect May 25, 2023, stated you would have to submit the required office notes via a dedicated fax number (833-462- 1360) or via email to Modifier25MedicalRecords@Cigna.com.

Resource: You can view the updated policy document here: https://static.cigna.com/assets/chcp/secure/pdf/resourceLibrary/ clinReimPolsModifiers/Notifications/Modifier_25_Significant_ Separately_Identifiable_Evaluation_and_Management.pdf. Watch for further updates from Cigna about when, and if, they will implement this policy or a revised version of the policy.