Cigna’s 2026 audit surge on modifier 25 usage for minor dermatologic procedures (CPT 11102‑11103): what documentation still holds up

The surprise clawbacks landing in Q1 2026

By February 2026, dermatology groups started getting Cigna audit letters demanding refunds on claims paid six to nine months earlier. The target: shave biopsy claims (CPT 11102‑11103) paired with an E/M code carrying Modifier 25. Cigna’s audit team alleges “insufficient documentation to support a significant, separately identifiable service.” The letters look almost identical across markets, quoting the 2025 reimbursement policy update from September 1, 2025, which tightened Modifier 25 review criteria for same‑day minor procedures.

Here’s the recurring pattern: the doctor saw a patient for a suspicious lesion, documented a brief exam, decided to do a biopsy, billed 99213‑25 and 11102 with the same diagnosis (usually D48.5 or L57.0). Cigna paid both, then six months later, withdrew the E/M payment, around $92 on average. Their claim: the E/M was not distinct enough from the biopsy decision.

What Cigna is actually pulling: line‑level review and “global same‑day conflicts”

This part has gotten ugly. In 2025, Cigna’s analytics began flagging providers whose E/M + 11102 combos ran above the 60th percentile of their dermatology peers. Their Cobden audit unit, the same one that chased 17000/17110 combos last year, is now running pre‑ and post‑pay edits tied to Modifier 25 frequency. They’re examining chart notes alongside claim histories. When the E/M and 11102 fall within the same encounter timestamp, reviewers expect documentation proving a condition separate from the biopsy site required additional evaluation or management. No distinction? They call it bundled.

The old workaround, throwing in a line about “reviewed patient history, discussed biopsy options”, no longer flies. That passed pre‑2025 audits, but not now. Cigna reviewers are applying CMS’s 2025 E/M language on “separate identifiable services” literally. There has to be another problem actively managed, like acne medication adjustment (L70.0) or evaluation of an unrelated rash. If the only reason for the visit is that lesion, your E/M is toast.

CMS documentation expectation hasn’t changed, but payer interpretation has

Modifier 25 rules from CMS remain the same in 2026. The baseline is still the Medicare Claims Processing Manual, Ch. 12, §30.6.7: when a minor procedure is done, the E/M is payable only if it goes “above and beyond” the pre‑op work. The big shift is in how commercial payers are enforcing that. Cigna’s 2026 policy leans on CPT Assistant’s 2025 clarification that procedure decision‑making alone does not justify Modifier 25.

That quiet wording change opened the audit floodgates. Cigna letters now cite both CPT Assistant and their own 2025 “E/M with Minor Surgery” policy, which requires a “separate diagnosis, illness, or symptom.” Their system cross‑checks diagnosis pointers, if both the E/M and 11102 map to D48.5, they call it bundled. This diagnosis‑matching logic didn’t exist before 2025, so many practices didn’t even realize they were exposed.

Medicare Administrative Contractors like Novitas and WPS aren’t denying these pre‑pay (yet), but they’ve signaled post‑pay reviews coming in 2026. CMS Transmittal 12289, released December 2025, instructed contractors to “review high‑volume Modifier 25 utilization for minor surgical codes.” So while Cigna’s leading the charge, this likely spreads wider soon.

What kinds of documentation still get paid

I’ve reviewed dozens of Cigna audit files in the last quarter. The only appeals that held up were clear about two problems being addressed. One patient came for a full‑body skin exam with actinic keratoses (L57.0) and also had a changing forearm lesion. The provider documented management for the AKs, cryotherapy deferred, topical 5‑FU continued, then decided to biopsy the lesion. The claim tied 99213‑25 to L57.0 and 11102 to D48.5. Cigna upheld payment. Two diagnoses. Two management tracks. That’s what wins.

Another case tanked because the provider argued the E/M was justified under the same D48.5 code, calling the counseling and consent “separate work.” Cigna denied the E/M even on level‑2 appeal, saying those steps are inherent to the procedure. The note was robust but lacked logical separation. You need distinct reasoning, not just words.

The simplest way to keep your E/M revenue safe: show and link a separate problem. Performing a shave biopsy on one lesion while managing seborrheic dermatitis (L21.9) or adjusting medication for acne? Write that out, and map the E/M line to that ICD‑10. Timestamp everything. If your E/M section clearly comes before the procedure and addresses other findings, auditors have less ground to say it’s bundled.

Financially, each lost 99213 means about $85‑$95 gone. Multiply that by a thousand biopsies, and a mid‑sized derm group could see $90,000 vanish in recoupments. Better to rewrite templates now than chase appeals later.

What to do before Monday morning

Run an internal query on 99213‑25 + 11102/11103 combos from Q4 2025 and Q1 2026. Sort by diagnosis pointers. If over 70% of pairs share the same ICD‑10, you’re lighting up Cigna’s dashboard. Have providers start labeling distinct conditions right in their notes, something like “Problem 1: actinic keratosis, ongoing management. Problem 2: changing nevus, biopsy done.” One clear sentence like that stops a denial cold. When you appeal, quote Cigna’s own 2025 Modifier 25 policy language about “additional complaint or condition.” Make them live by it.

Look, Modifier 25 audits are heating up, and CMS already added them to the 2026 OIG Work Plan. Don’t wait for another clawback. Split your diagnoses, timestamp your reasoning, and make sure every 11102 documents why the patient needed more than just a biopsy. That’s the only thing still passing audit in 2026. And that’s how you keep Cigna off your back, at least for now.