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Industry Insights

Cigna to Cap PC Clinical Pathology Reimbursement at $5 Beginning July 1
By: Amy Keil, Client Manager Letters from Cigna dated on or around April 1st, 2022, are not an April Fools’ Prank. It appears that Cigna is attempting a new additional tactic to manage their payment of the Professional Component of Clinical Pathology (PCCP). In this letter Cigna has indicated that their intent is to cap the reimbursement at $5.00 per test rather than stopping payment altogether. Cigna states that they took one or more of the following into consideration to establish this new policy.
  • Cigna’s existing policies
  • Industry standards
  • Centers for Medicare and Medicaid Services (CMS) guidance
  • Professional Society recommendations
  • Evidence-based medicine
The result of their review of the above, reimbursement will be capped for CPT codes billed with a 26 modifier, when the professional/technical component (PC/TC) payment indicator is 3 or 9.
  • 3 = Technical component only codes – 26 and TC modifiers are not valid
  • 9 = Concept of a professional/technical component does not apply – 26 and TC modifiers are not valid
These indicators can be found on the CMS Website and include all clinical laboratory CPT codes.  The new policy goes into effect on July 1st, 2022.  This policy follows Cigna’s two other attempts to discontinue payment for PCCP. Cigna first announced its intention to cease payments for PCCP last April; however, pushback from the College of American Pathologists and others led to several delays and revisions of that policy. Prior to this announcement, Cigna agreed in December it would continue paying PCCP unless the facility where the services were provided is contractually responsible for the laboratory management and oversight services. Cigna’s policy updates are available on the Cigna for Health Care Professionals website (CignaforHCP.com) >Resources>Coverage Policies>Policy Updates, or you can call Cigna Customer Service at 800-882-4462. We will continue to follow this for any updates before the policy change on July 1st, 2022. Interested in learning more about coding audits or improving your overall revenue cycle management? Contact us today for a free consultation.  

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