An upcoming policy from Cigna Healthcare will focus on codes for office visits, but the move is concerning one spine surgeon.
Effective Oct. 1, Cigna’s new Evaluation and Management Coding Accuracy policy will review CPT evaluation and management codes 99204-99205, 99214-99215, and 99244-99245 for billing and coding accuracy. Some services may be adjusted by one level.
Four- and five-level visits would include patients who are being seen for multiple areas of their body, but how a visit is coded is often based on decision making, Adam Bruggeman, MD, told Becker’s.
“If you made the decision that they needed surgery, that helps bring a code up,” he said. “If you had to order imaging and interpret images, that is what brings the code up to a higher level. So it’s not uncommon that, because we’re ordering a lot of imaging, interpreting a lot of imaging, and making decisions from surgery, that a lot of patients are being coded at levels four and five.”
Dr. Bruggeman said he’s worried that this policy will lead physicians to undersell their work to insurers.
“I think that the effect of these types of policies is to force doctors to under-code their claims,” Dr. Bruggeman said. “A physician might say, ‘Well, I think that’s a level four claim that I don’t want to get dinged, so I’m just going to call it level three.’ They might intentionally undercode their claims to stay off of the radar or to not get claims adjusted, and that’s not ideal. They did the work and should get paid for the work they did. In an era where reimbursements continue to decline, attacking those really commonly built codes is a huge win for the insurance companies and a huge loss for independent physicians.”
A spokesperson for Cigna told Becker’s that the updated policy is expected to affect a small percentage of physicians, and they have been “proactively” notified about the policy. The change was developed in response to the American Medical Association’s guidelines, a spokesperson said in an Aug. 19 statement.
“To better align with the American Medical Association’s (AMA) Evaluation and Management (E/M) services guidelines, Cigna Healthcare will implement a new reimbursement and coding accuracy policy for E/M codes that are being inappropriately billed as a higher level,” the statement said. “This review will only apply to approximately 3% of in-network physicians who have a consistent pattern of coding at a higher E/M level compared to their peers. Claims will be individually reviewed for coding accuracy and payment may be adjusted by one level to meet AMA guidelines. Physicians may request reconsideration or appeal our decision if they feel the higher payment is appropriate.”
