The California Medical Association (CMA) has learned that Cigna is re-releasing its policy to require the submission of medical records with all Evaluation and Management (E/M) claims with CPT 99212-99215 and modifier 25 when a minor procedure is billed. The updated Cigna policy – Modifier 25-Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service – is scheduled to become effective nationwide on May 25, 2023.

In May 2022, Cigna first notified providers that it would begin requiring the submission of medical records with all Evaluation and Management (E/M) claims with CPT 99212-99215 and modifier 25 when a minor procedure is billed. CMA opposed the policy and sent a letter to Cigna outlining its concerns, urging the payor to rescind the policy that effectively penalized physicians for providing efficient, unscheduled care to Cigna enrollees.

In its letter, CMA outlined that the policy would result in significant, unnecessary administrative burden and compliance cost to physician practices, would disincentivize physicians from providing unscheduled services and would create duplicate requests thus wasting health care dollars. The policy also lacked clarity on product types impacted, was inconsistent with industry standards and CMS guidance, and appeared to violate California law.

As a result of CMA advocacy, Cigna announced in July 2022 it was pausing implementation to reevaluate the policy.

Unfortunately, Cigna recently announced it will be moving forward with, essentially, the same policy effective May 25, 2023. The policy continues to pose a significant and unnecessary burden on physician practices and may be inconsistent with California law. CMA believes a more collaborative approach to identify alternative methodologies for cost containment that do not bluntly penalize physicians using the modifier appropriately will prove more effective and less costly in the long term. 

CMA, the American Medical Association and other state and specialty societies are reaching out to Cigna regarding our ongoing, significant concerns with this policy.

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 economicservices@cmadocs.org.