AAFP, Others Denounce Cigna’s Modifier 25 Coverage Change

In 2017, for instance, the AAFP strongly advocated in opposition to an Anthem coverage that may have decreased fee for E/M providers by 50 p.c when billed with modifier 25. After the insurer backed away from that proposal however nonetheless deliberate a 25% lower, the Academy, the AMA and different medical specialty teams continued to protest the transfer, ultimately securing a good final result.

It’s essential for members to know that the Academy frequently meets with nationwide payers and participates in coalitions to advocate for insurance policies that cut back physicians’ administrative burden, mentioned Stacey Bartell, M.D., AAFP medical director for profession and apply. Equally, the AAFP collaborates with state chapters to deal with regional insurance policies. On the federal stage, she added, the AAFP advocates for laws and regulatory coverage that eases administrative complexity.

On this newest occasion, the AAFP famous that Cigna’s announcement indicated the brand new coverage was the “results of a latest assessment” however did not reveal any findings that may benefit such a change. The Academy known as for “extra focused approaches which might be primarily based on legitimate information and up to date as conduct modifications over time moderately than penalizing all physicians.” Particularly, the AAFP urged that Cigna “determine doctor outliers and implement insurance policies that guarantee the proper use of modifier -25 for these physicians and/or practices.”

Indiscriminate software of such insurance policies, the AAFP warned, “add to the executive burden confronted by physicians and their employees and drain apply sources to look after sufferers.”

AMA-led Outreach Particulars Similar Issues

After reiterating this message throughout its annual assembly with Cigna, the AAFP additionally signed on to an April 18 AMA letter that known as on the insurer to instantly rescind the coverage “as a result of its unfavourable influence on apply administrative prices and burdens throughout medical specialties and geographic areas, in addition to its potential unfavourable impact on sufferers.” The letter was co-signed by greater than 100 nationwide and state medical associations.

Just like the AAFP, the teams expressed doubts concerning the foundation for Cigna’s motion, particularly the assertion that “‘evidence-based medication, skilled society suggestions, Facilities for Medicare & Medicaid Companies (CMS) steering, trade requirements, and/(or) . . . different present insurance policies’” performed a task within the insurer’s resolution.

“We query what requirements or tips Cigna consulted in initiating this coverage change,” the teams wrote, “because the CPT description clearly states that modifier 25 permits reporting of a big, individually identifiable E/M service by the identical doctor or different well being care skilled on the identical day of a process or different service. The medical vignettes included in a March 2023 CPT Assistant article illustrate the robust medical foundation for the usage of modifier 25 to assist efficient and environment friendly care.”

Moreover, the teams famous of their letter, “By facilitating the availability of unscheduled, medically mandatory care, modifier 25 helps immediate prognosis and streamlined therapy — which in flip promotes high-value, high-quality, and patient-centric care.”

Coverage Would Exacerbate Administrative Burden

Significantly problematic for each physicians and Cigna, in accordance with the letter, is that compliance with the coverage requiring medical documentation for all such claims signifies that “physicians and different suppliers shall be pressured to submit an unlimited variety of workplace notes, and Cigna shall be deluged with medical information” — solely about 10% of which might be reviewed below this system, the insurer had beforehand said.

“That is going to be a heavy burden on practices that already don’t have sufficient employees to assist the work,” mentioned Bartell. “Some practices will watch for the rejection to submit a duplicate of the progress notes, whereas others might want to attempt to construct stopgaps into their billing programs, and notes will should be manually submitted. Both means, this can result in an incredible improve in administrative work and possible delay in fee.”

In response to the AMA letter, the burden this course of would pose for physicians is additional sophisticated by the strategies Cigna has designated for submission of the required documentation (some extent the AAFP additionally raised in its letter) — that’s, both by fax or through an e mail tackle created for this goal. Nonetheless, Cigna failed to deal with the necessity to safe protected well being data in its announcement, inserting each well being care professionals and Cigna prone to HIPAA noncompliance.

Privateness and Safety of Affected person Knowledge Imperiled

The prices related to implementing and sustaining a safe e mail system to adjust to this requirement would impose one other undue burden on doctor practices, mentioned the letter, calling for that expense to be borne by Cigna.

“As a result of there is not going to be a safe portal for submission, we anticipate this can result in additional delays in fee, as processing all of those submissions manually may require a big period of time,” Bartell mentioned.

Total, she concluded, “We anticipate this may occasionally discourage the proper use of those codes for providers, subsequently requiring that the affected person return sooner or later for extra providers, resulting in a delay in care and decreased entry in an already overburdened system.”

The letter concluded with a suggestion to accomplice with Cigna on a collaborative academic initiative to make sure right use of modifier 25 with out unfairly punishing nearly all of physicians and different well being care professionals who code appropriately. Parts of such an initiative ought to embody selective engagement with physicians and different well being care professionals who’ve sudden coding patterns, schooling on right coding practices and, if wanted, documentation necessities restricted to those that present constant patterns of miscoding.