Cigna Reimbursement Policy Change: Office Notes Required to Bill E/M Service Separate from Same-Day Minor Procedure

Featuring: Jennifer Walen | Senior Vice President of Physician Revenue Cycle Operations

Featuring: Julie Appleton | Vice President of Coding Services

More than 50 policy updates were issued by Cigna in March. Among these updates was the reinstatement of a previously paused policy that requires the submission of office notes when an Evaluation and Management (E/M) service or office visit is billed in addition to a minor procedure on the same day of service. This change is scheduled to go into effect on May 25, 2023.

Cigna announced the roll-out of this policy in 2022 but halted implementation after the American Medical Association and California Medical Association objected to the “significant, unnecessary administrative burden and compliance cost” the proposed policy would place on providers. Medical societies are collaborating to contest this policy yet again, with The American Podiatric Medical Association calling it a “deeply disturbing and onerous new policy” that is “unjust” and “distracts from providers’ ability to care for their patients.”

This policy states that any E/M service that is separately identifiable from a minor procedure performed on the same day, as indicated by modifier 25, must be submitted with office notes to substantiate that the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided. The E/M line will be denied if Cigna does not receive what they deem to be adequate documentation to support that a significant and separately identifiable service was performed.

Who This Policy Impacts

The extent to which this policy impacts your organization depends on your practice patterns. Do you perform minor procedures in addition to standard E/M services? How many Cigna patients do you see monthly? While all providers that perform E/M with minor procedures will be impacted, rural physician practices are likely to be more impacted by this policy as they typically perform more minor procedures in lieu of referring patients to other specialized sites of care.

How to Prepare for the Policy Impact

Submitting office notes with all claims using modifier 25 to indicate a separately identifiable E/M service and minor procedure means providers and revenue cycle professionals will spend more time and resources billing these claims. Providers will also likely experience delayed reimbursement and increased denials as Cigna reviews the high volume of documentation associated with this change and evaluates if it’s adequate.

Key considerations to ensure accurate reimbursement from Cigna for claims using modifier 25:

  • Train coding teams on what constitutes a “significant and separately identifiable service.” If the procedure was planned or if the new problem didn’t require significant evaluation, don’t code a separate E/M service.
  • Prepare to have full office notes evaluated by Cigna. Reinforce documentation standards to prevent unforeseen issues and prepare revenue cycle teams for the increased work effort required to submit complete documentation with these claims.
  • Submit the medical records proactively at billing indicating the records support the use of modifier 25 appended to the E/M code.
  • Consider notifying patients their statements could be delayed due to Cigna’s policy change and the time required to review all submitted documentation and determine reimbursement.
  • Prepare for payment delays and an increase in denials for these claims. Evaluate what revenue impact this subset of claims will have on your organization.
  • Review your Cigna contract for language that prevents material financial changes to reimbursement. If you have this language, consider leveraging this to negate the application of this policy to your practice.

Key Takeaways

Cigna’s planned implementation of this documentation requirement continues the trend of payors increasing the burden on providers to prove the accuracy of their claims before payment is even considered. 

If this policy isn’t successfully stalled for a second time, it will go into effect on May 25. Providers must work quickly to adapt to this change to avoid unnecessary payment delays or denials for appropriate E/M services. Ensure coding and revenue cycle teams understand the documentation requirements and are equipped to accurately submit impacted claims. Evaluate the revenue impact delayed reimbursement or increased denials will have on your organization and prepare your patients for potential statement delays.

At a time when median operating margins remain negative for providers, complying with increasing payor complexity without incurring significant cost is critical. If your organization needs help adapting to changing payor policies to ensure complete and timely reimbursement, contact our team of revenue cycle experts today.

Jennifer Walen leads Ensemble’s physician revenue cycle operations across more than 20 hospitals and physician practices. Jennifer has more than 30 years of healthcare revenue cycle experience working for both providers and payors across the industry.

Julie Appleton has 25 years of experience as a medical coding and compliance expert in hospitals across the southeast. At Ensemble, Julie leads HIM and coding teams focused on physician revenue cycle to ensure complete, accurate and consistent coding for nearly 9,500 healthcare providers across the country.

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials.Neither Ensemble Health Partners, nor any of its employees, are your lawyers.Please consult with your own legal counsel or compliance professional regarding specific legal or compliance questions you have.