Category: Business

The Texas Medical Association and American Medical Association are monitoring the issue.

Carra Benson, TMA’s manager of practice management and reimbursement, says this new policy – and similar ones from other commercial payers – could prove to be “an administrative nightmare” given the ubiquity of office visits that include a minor procedure.

For instance, a dermatologist may discover a concerning mole and remove it during the same routine office visit. Likewise, a family medicine physician may see a patient for a scheduled joint injection and learn the patient has been experiencing chest pain and shortness of breath. If the physician sends the patient for a chest X-ray and electrocardiogram, then the physician would bill for the office visit related to the acute symptoms as well as the originally scheduled minor procedure, according to the American Academy of Professional Coders.

In coding terms, this policy change applies to evaluation and management codes 99212 through 99215, when billed with a modifier 25. That modifier is used to indicate a minor procedure, of which there are more than 1,600.

Ms. Benson says practices that often bill for such visits could find themselves overwhelmed by medical records requests from Cigna. This burden would fall especially hard on solo and small practices, which have limited staff to meet such demand, she adds.

Practices may opt to schedule follow-up visits for the minor procedure or to sever their relationship with Cigna to get around this administrative burden, Ms. Benson says. Both options constrain patients’ access to timely, continuous care.

She adds that if physicians choose to respond to Cigna’s records requests, they may be financially penalized – in the form of a refund request – for inadequately documenting the reason for the minor procedure.

Cigna did not provide a reason for the policy change in its notification letter to physicians and other health care professionals.

Blue Cross and Blue Shield of Texas also may request medical records and itemized bills from physicians and other health care professionals “to validate the site of service, level of care rendered, and services billed were accurately reported,” according to its clinical payment and coding policy.

UnitedHealthcare policy doesn’t mention medical record requests in the context of office visits with a minor procedure, but Ms. Benson says practices may still see the issue arise.

Practices that have received notice from Cigna or are dealing with negative ramifications related to similar policies can request a coding and documentation review from TMA Practice Consulting. The service includes an in-depth review of medical record documentation and claims coding that identifies deficiencies and areas of risk.