May 10, 2023
As a result of advocacy by the California Medical Association (CMA) and other state specialty societies, Cigna has again delayed implementation of its policy requiring the submission of medical records for all Evaluation and Management (E/M) claims billed with CPT 99212-99215 and modifier 25 when a minor procedure is billed. The policy, originally scheduled to become effective May 25, will be delayed until June 11.
Cigna has advised CMA that the policy, when implemented, will not apply to fully-insured products regulated by the California Department of Managed Health Care or the California Department of Insurance (also referred to as CHC-CA and CHLIC). For these products, Cigna will continue to allow reimbursement when modifier 25 is appropriately billed with an E&M code without the need to submit medical records.
Unfortunately, Cigna’s large population of self-funded, Administrative Service Only business in California – representing over 70% of the total lives in the state – will remain subject to the modifier 25 policy.
CMA has stressed to Cigna and regulators that there is no reliable means to identify which patients have a fully-insured vs. self-funded product so practices can know whether the policy applies. Absent clear identification of the product type for each patient, the exemption for fully insured products is meaningless.
CMA continues to discuss our concerns with Cigna, advocating for a more collaborative approach to identify alternative methodologies for cost containment that do not bluntly penalize physicians using the modifier appropriately.
Practices with questions or concerns are encouraged to contact Cigna Customer Service at (800) 88Cigna (882-4462).
Practices can also contact CMA at (888) 401-5911 or firstname.lastname@example.org.