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Cigna Requires Medical Records for all E/M Services Billed with a 25 Modifier

Cigna, one of the largest health insurance providers in the United States, recently announced that it will require medical notes for all claims billed with a 25 modifier. This new requirement has caused concern among healthcare providers, as it could lead to increased administrative burden and delays in payment.

What is the 25 Modifier?

The 25 modifier is used to indicate that a significant and separately identifiable evaluation and management (E/M) service was provided on the same day as another procedure or service. This modifier allows providers to be reimbursed for both the E/M service and the procedure or service performed on the same day.

Why is Cigna Requiring Medical Notes for Claims with a 25 Modifier?

Cigna has stated that the new requirement is part of its ongoing efforts to combat healthcare fraud and abuse. By requiring medical notes, Cigna believes they will ensure that the services billed with a 25 modifier are medically necessary and appropriately documented.

What are the Concerns of Healthcare Providers?

Healthcare providers have expressed concern that the new requirement will lead to increased administrative burden and delays in payment. Providers may need to increase time spent on documenting their medical notes to ensure that the services billed with a 25 modifier meet Cigna's requirements. Additionally, providers will experience delays in payment as claims are held up for review.

More importantly is Cigna's assumption they, as a healthcare insurer that is responsible to pay claims, are best to make the decisions around what is medically necessary and what is not. It is easy to see a company that is responsible for making payments would also be responsible for deciding if they should have to pay for claims.

As of 2023, we have seen an enormous increase in the request for medical notes for all claims. The requests are time consuming to process, and in additionl create denied claims for varies reasons, such as invalid formats, lacking details and documentation. This further delays claims processing and can lead to needing to go into and official appeals process, which is even more time consuming.

Some providers have also expressed concern that the new requirement may disproportionately affect small practices and those in underserved areas, who may have fewer resources to devote to administrative tasks.

American Academy of Professional Coders (AAPC) discusses this new rule in an article that can be found here.

The American Medical Association and state and specialty societies have significant concerns with this policy. The California Medical Association (CMA) sent a letter to Cigna outlining its concerns, urging the payer to rescind the policy. “This policy will impose an estimated cost of $3.29/per claim to produce the record and fax to Cigna, which will result in a net payment reduction. … This is a complete waste of health care dollars and practice time that would be better spent providing care to patients,” said CMA President Robert E. Wailes, MD, in the opposition letter.

What Should Healthcare Providers Do?

Healthcare providers who bill Cigna for services billed with a 25 modifier should be prepared for slow and delayed payments for any services they bill that appends the 25 modifier (any E/M code billed with any other service or procedure).

In addition, providers should ensure they implement the most efficient workflows to combat the increasing demands related to billing and insurance reimbursements.

Contact us today for more information on making sure your workflows are up to date and efficient.


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