Cigna backs off documentation requirements

After organized medicine objections, Cigna amends its list of when documents are needed for coding modifiers.

By Emily Berry — Posted May 11, 2009

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Cigna has retreated from a previously announced change to reimbursement policy that would have required physicians to submit documentation to support claims for as many as 17,000 pairs of services.

The insurer announced in January it would require documentation in thousands of cases where multiple services were coded along with the 25 or 59 modifier under Current Procedural Terminology. The new requirements were set to go into effect April 20.

However, after discussions with the American Medical Association and state medical societies who passed on physician concern over new administrative burdens, Cigna reduced the number of pairings that require documentation to about 200. The AMA and state societies alerted physicians that the amended list went into effect April 27.

"Physicians will still be able to submit claims accurately and with appropriate documentation, but the policy will now eliminate the administrative burden imposed by the increased documentation requirements," said AMA President Nancy H. Nielsen, MD, PhD. "The policy change is good news for physicians who continue to divert substantial resources into a costly and time-consuming reimbursement process."

The 25 modifier is used to indicate "significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service."

The 59 modifier indicates a "distinct procedural service," and under CPT definition is "used to identify procedures or services other than (evaluation and management) services that are not normally reported together but are appropriate under the circumstances."

Prior to federal class action HMO litigation settlements reached beginning in 2003, it was common for plans to edit out the modifiers.

That was true of Cigna prior to its signing on to the federal class-action settlement in 2004, said Doug Hadley, MD, director of Cigna's Coverage Policy unit.

However, from the time it signed on to the settlement until August 2007, Cigna required documentation that supported a 25 or 59 modifier any time it was used, Dr. Hadley said. Cigna eliminated the requirement as a way to cut down on doctors' administrative work, he said.

Cigna's HMO settlement agreement expired last year, but the company promised to continue to recognize modifiers except where there was some irregularity.

"We subsequently looked at claims submitted, and we had a large increase of use of 25 and 59, above expected trend," Dr. Hadley said.

The plan's first reaction was to return to requiring documentation for 17,000 code pairings that are edited out of Medicare claims as part of the National Correct Coding Initiative, Medicare's claims editing system.

But doctors rightly pointed out that that policy would represent a significant administrative burden for physicians and their staffs, Dr. Hadley said.

Connecticut State Medical Society Executive Vice President Matthew Katz said Cigna responded appropriately.

"There was initially confusion and frustration because of what appeared to be a backtracking from a commitment," he said. "What they have correctly done ... is recognize that what they were asking would have created undue problems for physicians."

Cigna is asking physicians who submit claims electronically to indicate when they are sending documentation separately.

Dr. Hadley said the company will pay the claim on good faith so payment isn't delayed pending review of records.

Meanwhile, Cigna has taken a step to honor another commitment it made last year, this to ensure its physician tiering program is based on evidence-based guidelines and not on cost, and allows for physician review and appeal.

The National Committee for Quality Assurance has approved Cigna's physician quality and cost measurement programs in its first certification under new standards set last year.

Dick Salmon, MD, PhD, a family physician who is Cigna's national medical director, said the new certification also means Cigna has satisfied the conditions of the Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs, a pledge it and other large national health insurers signed in April 2008.

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