https://www.horizonhealthcarercm.com/wp-content/uploads/2025/06/Denial-Management-101-Strategies-for-Managing-Unpaid-Aging-and-Denied-Claims.jpg 1250 2000 AbstraktMarketing /wp-content/uploads/2022/06/Horizon-Logo.png AbstraktMarketing2025-06-24 14:30:132025-06-27 16:24:45Denial Management 101: Strategies for Managing Unpaid, Aging, and Denied ClaimsWhat Is Billing Modifier 25?
Most medical practices are familiar with the use of Modifier 25 for separately billable evaluation and management (E/M) services performed during minor office procedures. While the use of billing Modifier 25 allows providers to be reimbursed for both the E/M service and the minor procedure, the medical necessity of the separately identifiable E/M service must be documented in the patient’s record.
New Requirements for Cigna Modifier 25 Policy
In the past, Cigna didn’t require healthcare providers to include their supporting notes of Modifier 25 usage in E/M service claim submissions. However, as of May 25, 2023, Cigna is requiring healthcare providers to submit their office notes supporting the use of Modifier 25 every time to ensure that adequate documentation is received to support that a significant and separately identifiable service was performed.
Cigna’s new reimbursement policy for Modifier 25 states that E/M services provided must meet the criteria as defined in the current CPT® E/M guidelines for code section 99202 – 99215 and 1997 CMS documentation guidelines. Additionally, they advise you to submit your documentation with a cover sheet indicating that the office notes support the use of Modifier 25 appended to the E/M code.
Although the policy became effective on May 25, 2023, in most states, there may be different dates in other locations. For instance, the policy doesn’t start until June 11, 2023 in Texas, so check with your Cigna representatives to see when it starts in your state.
Only Approved Vendors Can Electronically Upload Records
If you’re an approved vendor for Cigna, you can upload your documentation electronically. However, if you’re not an approved vendor, it’s a different story. You must fax, email or mail your records. This can be problematic for practices because it’s easy for claims and associated medical records to become separated, leading to mismatched documentation and unnecessary denials.
If you’re looking for ways to ensure that your records get matched up with your claims in a timely manner, it’s a good idea to reach out to your Cigna representative and ask how you should be submitting your documentation. They should be able to give you advice on what type of information to include in your submissions.
Explaining the Proper Use of Modifier 25
To use Modifier 25 correctly, the unrelated service or procedure must be significant enough to be billed separately. The procedure or service must also be above and beyond what is included in the major procedure or service. The most important thing to remember when using Modifier 25 is that you must document the reason why the minor procedure or service was performed on the same day as the major procedure or service. You must also ensure that all services billed with Modifier 25 are medically necessary and documented appropriately.
Examples of Incorrect Use of Modifier 25
While Modifier 25 can be beneficial when used properly, incorrect use can lead to errors in coding and reimbursement. For example, appending Modifier 25 to a CPT or HCPCS service code that’s not an E/M code is incorrect use. Additionally, Modifier 25 shouldn’t be used when the patient’s condition doesn’t warrant an E/M service in addition to the procedure performed on that date.
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How to Identify Your Significant, Separately Identifiable Claims
Significant
The E/M service provided should be significant and not cursory, meaning that the service should include more than the preservice work involved in performing the procedure. For instance, if you’re administering an injection to a patient, the E/M service would include any explanations or discussions with the patient before administering the injection. This is important, as these pre-service activities aren’t included in the payment for the injection procedure itself.
Separately Identifiable
To ensure that your medical record reflects accurate E/M services, there should be no overlap in the work associated with the E/M service and the actual procedure. That means that the documentation for the E/M services should accurately reflect the work you did for that service, and not be part of the documentation for the procedure itself. If you cannot separate out and lift your E/M documentation out of your medical record and leave behind enough documentation to support the procedure, then you can’t report both.
Cigna Modifier 25 Policy Update Summary
The healthcare industry is constantly evolving and, as a result, health insurance providers are constantly updating their policies to keep up with the times—Cigna is no exception to this rule.
Fortunately, our team of experienced coders and billing specialists at Horizon Healthcare RCM are well-versed on Modifier 25 requirements, including the policy update. Contact us today to learn more about how we ensure your claims are properly reimbursed with our medical billing and coding services.
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