Providers submitting claims to Cigna: Make sure to read the private payer’s latest Professional Claims Code Editing and Documentation Requirements Guidelines. Effective April 27, the company now requires supporting documentation for some claims containing modifiers 25 and 59.

Cigna has begun requiring documentation for a specific subset of edits the Centers for Medicare & Medicaid Services (CMS) and the National Correct Coding Initiative (NCCI) designate as “1″ (allowed).

For modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service, supporting documentation is now required on 73 code combinations.

Exception: Documentation is not required to override the edit between problem-based and preventative office visits.

For modifier 59 Distinct procedural service, supporting documentation is now required for 121 code combinations.

Remember: Modifier 59 is not appropriate for use with E/M service codes.

To view the updated list of affected CPT® codes, log into the Cigna Web site and click Resources > Claim Editing Procedures.

9 Responses to “Cigna: 25 and 59 Require Documentation”

1. Ruth Dolby Says:
   May 6th, 2009 at 2:56 pm

   How do you view the updated list of CPT codes that Cigna now requires the notes when modifier 25 is used. I went into the Cigna site as you suggested, but the site was not active.

   Thank you.

   Ruth Dolby

2. Christina Rossi Says:
   May 6th, 2009 at 5:24 pm

   The link to the Cigna website you provided above does not work to view the updated list of CPT codes Cigna requires when using modifier 25/59. Please give further directions. Thank you!

3. Lisa W Says:
   May 7th, 2009 at 6:55 am

   I clicked on the link in the first sentence of the article. It works. You will need to log in as a provider.

4. Debbie H Says:
   May 7th, 2009 at 8:08 am

   How are we suppose to submit documentation when using modifier 25/59 if Cigna will not accept paper claims from our providers?

5. Christina M Says:
   May 7th, 2009 at 10:04 am

   Regarding the paper claim issue, we send in the claim with or without the modifier and then sending a corrected later with requested notes via fax, I just did faxed some today. It may take longer to get paid but it seems to work for our small facility. Hope that helps.

6. Cindy C. Says:
   May 10th, 2009 at 9:24 am

   This is how you can access the CG site “Claim Editing Procedures” as well as many other claim items:

   1. Go to http://www.cigna.com
   2. On the left side in the green shaded box, click Health Professionals.
   3. Click Medical
   4. Claim Editing Procedures is the first listed item

   As a side note, you also can access the medical criteria for CIGNA precertification of most procedures. If you can find one on the site, for example, Gastric Bypass, call the 800 number for precertification and ask them to fax you their criteria.

   To access the criteria on site:
   1. Go to http://www.cigna.com
   2. On the left side in the green shaded area, click Health Care Professionals
   3. Under Policies, Procedures, Guidelines, click Coverage Policies.
   Most of their procedures requiring precertification are listed here in alpha order.

   Another useful site is the Preventive Care Guidelines which is under the same category, Policies, Procedures, Guidelines. Most member benefits are very specific about what their benefit pays for preventive care. For example, Colonoscopies: Some benefits will pay 100% for a “preventive colonoscopy”, but if a diagnosis code for anything other than a V code (rectal bleeding) is on the claim form it will NOT pay at preventive benefit but something like 50%. It is all in the wording of the benefit.

7. Peggy Says:
   May 11th, 2009 at 9:55 am

   Is there a way to view the list of code combinations for which Cigna requires documentation if you are not a provider?

8. Cindy C. Says:
   May 12th, 2009 at 5:52 am

   Peggy
   I’m assuming you have already tried asking CIGNA Claims for such a list. If you haven’t, try that first (you may have to ask to be transferred to a supervisor.) If that doesn’t work, try your Provider Relations Rep. He or she will have more “pull” with getting you some help. (If your rep is unresponsive, ask to speak to Provider Relations Manager and ask to have a new rep assigned.) I would think if there are code combinations that require documentation then there is a list to help the claim reps process them. (If you don’t know your Provider Rep, call CIGNA and ask to be transferred to Provider Relations. They should be able to tell you who your rep is.)
   Hope this helps. ~ Cindy

9. Amber E Says:
   July 22nd, 2009 at 5:27 am

   They automatically ahve been denying all of our claims billed with 59 modifiers. East way to get these paid faster is to submit the claim then fax office notes or operative reports to 1-570-496-2945. They will not process this with out documentation. A lot more work…that is the only way I am getting these paid. Any more suggestions?

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