Cigna and Modifier 25

“I just received a letter from Cigna insurance. As of August 13, 2022, they will require the submission of office notes with claims submitted with Evaluation and Management/E and M codes (ie. 99212, CPT 99213, CPT 99214) appended by modifier -25 when a minor procedure is also billed the same day by the same physician. The E/M will be denied if documentation is not received. The claim can be sent electronically with attachment indicator and notes should be faxed. Is this happening with other insurance companies? The amount of paperwork for a small office is crazy and along with continued decreasing reimbursements, higher prices for supplies, shortages, etc. The insurance companies are making greater profits than ever. The insurance premiums have increased and out-of-pocket patient billing has become more significant. The system is not right. What can we do? How do we fight back? Please don’t say take cash rather than insurance, it’s not practical in many circumstances. Any thoughts?”

This totally does not surprise me at all. The 25 modifier allows for the payment/reimbursement of an evaluation and management (ie. E/M) service that is performed and billed for on the same date of service that a minor surgical procedure is performed and billed for, as well. By definition, a minor surgical procedure is a CPT code that has a global period of “0” or “10” days.

The key to being paid for the E/M service and the procedure is understanding the appropriate use of the 25 modifier. It is defined as the following: SIGNIFICANT, SEPARATELY IDENTIFIABLE E/M SERVICE BY THE SAME PHYSICIAN ON THE SAME DAY OF THE PROCEDURE OR OTHER SERVICE. Bottom line? The 25 Modifier is used to demonstrate that a SIGNIFICANT, SEPARATELY IDENTIFIABLE E/M service was performed on the SAME day of a MINOR surgical procedure by the SAME physician.

With the exception of traditional Medicare, the Medicare advantage plans and the commercial health insurance carriers, for the most part have been automatically rejecting the E/M service when it was billed on the same date of service as a minor surgical procedure code. The providers would need to challenge and appeal the decision that was made by the health insurance carriers in question in order to prove that the E/M service that was billed appended by the 25 modifier was indeed significant and separately identifiable. How successful were the appeals? Not very successful.

What Cigna is apparently doing now is requiring the provider to submit the documentation in the medical record for the date of service in question to demonstrate that the E/M service appended by the 25 modifier is significant and separately identifiable allowing for the reimbursement of the E/M service. I suspect that there will be a high incidence of rejections, once again forcing the providers to appeal the decisions that were made to not reimburse for the E/M service when performed with the procedure. I suspect that if Cigna is taking this position, don’t be surprised if other commercial health insurance carriers follow suit.

In order to understand precisely what a significant and separately identifiable E/M service actually is, please note the following:

1. 1.    ALL CPT (procedure) codes have an inherent E/M component
2. 2.    2. In order to bill an E/M service and a CPT code on the same date of service, whether it is an initial encounter or a subsequent encounter, you must through your documentation demonstrate the thought process that was used to extract the E/M component from the CPT code to make the E/M service significant and separately identifiable.

The big question that needs to be addressed is: Why is this E/M service significant and separately identifiable?

In order to have a chance at a successful appeal, it is important to understand the appropriate ways that the 25 modifier can be used to demonstrate that the E/M service is significant and separately identifiable:

1. 1.    An INITIAL E/M service CAN be billed when performed on the SAME date of service as a minor surgical procedure code.

*The diagnosis code for the initial E/M service and the diagnosis code for the minor surgical procedure CAN be the SAME.

1. 2.  An ESTABLISHED patient E/M code CAN be billed when performed on the same date of      service as a minor surgical procedure code.

            *The diagnosis code for the established E/M service MUST be DIFFERENT from the diagnosis code for the minor surgical procedure

            *There can be NO correlation between the E/M service and the minor surgical procedure.

1. 3.   If an established patient is seen for a NEW problem that the patient has never been evaluated for previously, and a minor surgical procedure is performed on the SAME date of service, then not only can BOTH the established patient E/M service code AND the minor surgical procedure code be billed for, but the diagnosis code for the E/M service AND the diagnosis code for the minor surgical procedure can be the SAME

              *Of course this needs to be documented in the medical record.

My last point is that with respect to traditional Medicare, with few exceptions whenever an E/M service is appended by the 25 modifier and is billed on the same date of service as the minor surgical procedure, the E/M service is reimbursed. This is pretty nice, right? There is a problem, though. The number one reason that podiatrists are audited and fail the audit is the inappropriate use of the 25 modifier. Post payment audits are occurring nationally. My advice? Make absolutely sure that if the E/M service is billed with the procedure on the same date of service, the documentation supports the appropriate use of the 25 modifier and the E/M service is significant and separately identifiable as described above.

This is my opinion.

Michael G. Warshaw

DPM, CPC

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Mount Dora, FL 32757

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