AMA ISSUESSTATEMENTREGARDINGCIGNA MODIFIER25 POLICY

Cigna has not provided any rationale for the policy and has not offered any evidence of overuse or unnecessary application of modifier 25. The AMA recently released a CPT® Assistant supplement entitled ?Reporting Modifier 25?which outlines various scenarios modifier 25 is appropriate:

Adding to physicians?concern regarding this policy is that Cigna has stated they will only review approximately 10%of the documentation submitted Furthermore, the payer has offered only two options for submitting the required medical records when reporting modifier 25: the rarely used method of fax, and a HIPPA non-compliant, unsecured email address.

The various physician organizations have approached Cigna to collaborate in distributing educational materials and joining forces for training initiatives

Palliativecarecoverageand Considerations

Frequent ly Asked Quest ions

1 The person hired t o do t he Palliat ive Care is a Nurse Pract it ioner Is t hat is a billable service?

Answ er: Services of a Nurse Practitioner are billable as professional fees, provided of course that the services billed are medically necessary and the nurse practitioner is properly enrolled with the payer.

2. Our Nurse Pract it ioner w ill be seeing bot h inpat ient s and out pat ient s in t he hospit al She m ay also be seeing pat ient s in t heir hom es

Be sure the NPis enrolled with Medicare and included under your medical group NPI with an 855B form (or on PECOS) no more than 30 days prior to the date on which the NPwill begin seeing patients.

The NPmust also update the NP?s individual Medicare enrollment (855I/PECOS) to add locations of service which include the facility and patient home visits. NPservices billed as professional fees will be reimbursed at 85%of the Medicare physician fee schedule (CAH Method II note: nurse practitioner services in the outpatient hospital setting must be billed with modifier -GFappended to the CPT® code on the UB/837i.)

Verify that the appropriate E/M codes are available with in the chargemaster, and ensure that the appropriate Place of Service codes are also reportable Typical professional fee codes would include, but not be limited to the following:

Out pat ient visit s in the clinic or hospital setting: 99202- 99215

Inpat ient s ? 99221- 99223

Hom e or dom iciliary visit s ? 99341- 99350

Typical Place of Service codes:

21 ? Hospit al Inpat ient

22 ? Hospit al Out pat ient

12 - Hom e

13 ? Assist ed Living Facilit y

3 Are t here any guidelines for Palliat ive Care program s?

Answ er: The National Coalition for Hospice and Palliative Care offers a guideline at the link here: https://www nationalcoalitionhpc org/ncp/