Modifier 25 Pre-Bill Review: Were You Ready?

After all the hype surrounding the upcoming Cigna policy regarding modifier 25 and pre-bill reviews, it seems as if Cigna is not planning on implementing the policy as planned on August 14, 2022. At the time of writing, there is recent news starting to come out stating that Cigna has begun to inform national specialty associations of their decision to not move forward with the policy this August.

As I sit back and look at all of this as a compliance auditor, I still have the question in the back of my mind regarding whether practices really understand what the modifier 25 changes to the claim process and reimbursement can mean for them. Even though this subject is often discussed throughout our industry, I still find that there are practices that do not realize how much risk lies within E/M coding, and more specifically, in the use of the 25 modifier. When the Cigna modifier 25 news started to surface, I heard a mix of reactions. Some seemed to be completely unphased by what was up ahead, while others recognized the weight of what was coming their way.

There have been multiple times when I meet with a provider for post-audit education, and they are unaware of the fact that an E/M is not automatically billed each time the patient presents to the office. At times, not even understanding what the applied 25 modifier actually means when placed on a claim. The majority of groups that I work with do not have certified coders reviewing every note to validate the codes for the providers. While there is billing staff in the practices or it is outsourced, providers do not always understand that billing does not mean that a staff member is reviewing every note and it is not the same function as coding.

So, does Cigna stopping the implementation of their modifier 25 policy mean the practices are in the clear? No, it does not. From my perspective, this is a reminder to practices to be diligent when it comes to performing both internal and external audit reviews. Does your practice have a compliance plan and audit policy in place that ensures providers receive feedback on a regular basis? It can be easy to get caught up in the busyness of a practice. This is a great time to evaluate the volume of E/M services that your practice is billing with a 25 modifier and perform audits to evaluate the level of risk and identify areas for education.

While this upcoming news is great for practices that participate and bill Cigna, it does not mean that other payers will not continue to move forward in making changes regarding modifier 25. For example, some of the BCBS companies and Aetna have started to inform their network providers of their changes in policy and/or reimbursement for some claims that contain the modifier 25.

At the time of writing, I have not personally seen any information stating that BCBS or Aetna are changing their plans to implement change to their upcoming modifier 25 policies, but this is not the time to sit back and wait. Get out and attack this age-old subject to ensure our practices are compliant and equipped with workflow processes to make the transitions in payer's policies as painless as possible.

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Stephanie Allard, CPC, CEMA, RHIT
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