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Transcript:

I’m in Tucson this week and I received notification that Cigna has brought their Modifier 25 reimbursement policy back on track. They were going to institute this policy in May of 2022 and there was such a huge pushback that they rescinded it in July of 2022 — we all knew it was coming back, though, right? So …

Let me introduce myself I’m Nancy Johnson, I’m the founder of RevUp. We make certain independent healthcare providers collect all the money they are due.

As I said in May, ’22, Cigna instituted this policy where every ENM with a 99212 through 99215 established patient, anything that had a Modifier 25 on it, the claim needed to be submitted with documentation from the visit. And obviously what they’re looking for is justification for that Modifier 25. The administrative burden with this, obviously, is horrible in so many ways and for so many reasons not to mention it is not the most effective way to do education about the Modifier 25.

So, any claim that you submit to Cigna where the ENM 99212 through 99215 has a Modifier 25 must be submitted with documentation in order to avoid a denial.

So, a review of the coding requirements for Modifier 25 could take a solid ten minutes — more — we could do a whole hour on it — but it could take a solid ten minutes to just make sure that you are really coding properly. But for this topic that we’re talking about right now — quick overview — let me keep it simple.

So, let’s say for example you’re an ortho coder and you have an established patient who comes in, she’s got pain in her knee, she’s assessed by the physician who determines that she has osteoarthritis, very key in coding those Synvisc, let’s say, injections. So it’s a series of three injections, she has her first injection done at the initial visit. The ENM’s gonna have that Modifier 25 because she came in with pain, she was assessed to have osteoarthritis, so the injection, 20610 with a J, let’s say, 7325 for Synvisc is submitted on that claim. If it’s going to Cigna it needs to go with that documentation. After the visit when that patient schedules her two additional injections, those visits should only be the 20610 with the medication, the J 7325 for both of those visits. An ENM is not appropriate UNLESS she says, “you know I’m really having pain in my right ankle,” and the provider assesses that right ankle pain. That ENM has to have a Modifier 25 on that’s diagnosis code would be the right ankle pain, not the osteoarthritis for, say, the left knee.

But there’s definitely value if you’re a contracted provider with Cigna in writing them a letter and telling them about the administrative burden to be in support of your own practice. Thanks so much for stopping by and make sure you check out all the other videos we have available. Thanks so much, take care.

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