Cigna Reintroduces Policy to Stop Reimbursement for Professional Component of Clinical Pathology

On 9/27/2021 Cigna updated their Modifier 26 Professional Component Reimbursement Policy, detailing the correct and incorrect use of Modifier 26. Effective 10/27/21, Cigna will not provide reimbursement for codes incorrectly billed with a 26-Modifier.   

The reimbursement policy defines, incorrect use of Modifier 26 as:

• Application to any code not listed in the CMS National Physician Fee Schedule Relative Value File (NPFSRVF)
• Application to any procedure which does not have a technical component
• Application to any procedure which should be billed globally

Cigna’s M26 (Modifier 26 Professional Component) Reimbursement policy states:

“Cigna provides separate reimbursement for the professional component of the global fee at the fee schedule or other allowed amount when modifier 26 is appended correctly as determined by the Professional Component/Technical Component (PC/TC) indicators in the CMS Payment Policies provided in the National Physician Fee Schedule Relative Value File (NPFSRVF)”

Earlier this year in April, Cigna sent letters to several pathology practices regarding updates to the same policy referencing the CMS payment policy on modifier 26.  In June due to push back from multiple state and national organizations Cigna placed the policy on hold. 

However, per this recent update it appears effective 10/27/21 any claims submitted where the 26-modifier is applied incorrectly, for example on a clinical test that does not have a technical component per the NPFSRVF, will not be reimbursed.   This updated policy, could significantly impact pathology groups billing the professional component on clinical laboratory test.

XiFin encourages impacted clients to reach out to their state and national organizations on this issue.  Customer Account/Service Managers for current XiFin clients will assist in providing estimated financial impact to these changes.

The entire Reimbursement Policy can be found here Professional Component (cigna.com).

Additional XiFin news related to this policy:

• Cigna to Keep Paying for PCCP June 2021 

• Cigna to Stop Reimbursement for PCCP of Pathology Claims April 2021