Primary Care Coding Alert

Question: I’m seeing a lot of conflicting information. Did Cigna update their modifier 25 payment process?

Florida Subscriber

Answer: Your confusion is understandable. Cigna has gone back and forth on this topic. Here’s what we know:

Cigna had proposed to update their payer policies for providers seeking reimbursement for same-day procedures and certain evaluation and management (E/M) encounters. The new policy 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 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service) when the provider performed and billed for a minor procedure at the same encounter. Failure to submit records would have resulted in a denial of the E/M service.

In response to several advocacy groups who were concerned about administrative burden and compliance costs, on May 23, 2023, Cigna decided to delay implementation of this new policy. Cigna plans to reassess at a later date, but for now, the policy is on hold (https://static.cigna.com/assets/chcp/secure/pdf/resourceLibrary/clinReimPolsModifiers/Notifications/Modifier_25_Significant_Separately_Identifiable_Evaluation_and_Management.pdf).