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Defending Revenue Cycle Claims in Light of New Payer Policies

Analysis  |  By Amanda Norris  
   May 11, 2023

Cigna recently made a big change in how they will pay certain claims.

Organizations will need to stand firm on compliance and reimbursement when its revenue cycle team submits evaluation and management (E/M) claims with modifier -25 as Cigna recently dropped a new policy.

According to Cigna, it created a new policy requiring submission of office notes with all claims including E/M codes 99212, 99213, 99214, and 99215 and modifier -25 when a minor procedure is billed.

Cigna said it will deny payment for these E/M services reported with modifier -25 if records documenting a significant and separately identifiable service are not submitted with the claim, and medical groups were quick to show their frustration.

For background, the revenue cycle coding staff report modifier -25 for E/M services on the same day of another service or procedure when it is performed by the same physician or provider.

So how can revenue cycle leaders create a plan for their staff to defend these claims?

The good news is revenue cycle staff from all sections of the organization can play a part in defending the revenue for modifier -25 claims, according to a recent Part B News webinar. For example, providers must create documentation that supports the modifier, coders need to monitor private payers for new policies, and members of the A/R team will need to keep an eye on these denials.

It’s important that the revenue cycle keeps an eye on these denials, teams make sure the documentation supports modifier -25, and they are quick to appeal any of those claim denials.

Creating a template unique to this Cigna requirement will also help. Staff can then modify and use the template when documentation is provided for prepayment approval, when they respond to a request for documentation to support a claim, or when they appeal a denial of an E/M visit reported with the modifier.

If you submit claims to Cigna, you should also have a process to ensure the required documentation goes out with claims that include modifier -25. If you forget, you can expect more time and more work to get reimbursed, according to Part B News.

Another way to lessen the blow is to create a targeted approach to Cigna denials. “My denials team works by payer,” Frank Cantrell, corporate director of revenue integrity at Penn Highlands Healthcare recently said. “They know their contracts backwards, forwards, and sideways.”

Cantrell believes it’s important for his team members to be critical thinkers with a high level of understanding, which is a necessity since each payer contract has varying nuances.

Amanda Norris is the Director of Content for HealthLeaders.


Cigna recently announced it will deny payment for certain services if documentation is not submitted with the claim.

Revenue cycle staff from all sections of the organization can play a part in defending the revenue for these claims.

One leader has found that using a targeted approach by creating teams that work by payer has helped ward off denials.

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