Cigna is introducing a new Evaluation and Management (E/M) downcoding reimbursement policy effective October 1, 2025. This significant update will change how Cigna reviews and pays E/M claims, impacting medical offices, billing teams, and providers across the country.
Understanding these changes is critical to maintain proper reimbursement and compliance, safeguard revenue, and streamline claims management.
What is E/M Downcoding?
E/M downcoding happens when a payer reduces the level of the service code submitted by a provider to a lower level, which results in reduced payment - even if the higher level of care was actually delivered and appropriately documented.
This practice often results from automated claim edits, software algorithms, or a payer’s interpretation that the submitted documentation does not justify the higher service level.
Downcoding can have serious financial impacts on physician practices, especially when it becomes routine or widespread. Providers may receive payment for a lower level of care than was truly provided, harming practice revenue and increasing administrative burdens.
Overview of Cigna’s New E/M Downcoding Policy
Cigna's Evaluation and Management Coding Accuracy policy will specifically target high-level E/M CPT codes including 99204, 99205, 99214, 99215, 99244, and 99245.
Starting October 1, 2025, claims billed with these codes will undergo detailed review to ensure they meet the current AMA E/M coding guidelines. If documentation does not fully support the higher level code under these national standards, Cigna may lower the level by one step and reduce payment accordingly.
This policy expansion reflects Cigna’s goal to maintain fair and accurate reimbursement rates that correspond to care complexity, encourage proper documentation, and reduce inappropriate or unsupported billing.
Providers should prepare for increased claim scrutiny under this policy, with the understanding that payment adjustments may occur more frequently if documentation gaps exist.
While Cigna offers periodic audits and opportunities for providers to correct coding, compliance will be key to avoid unnecessary revenue loss.
Why Cigna is Implementing This Policy
Since the evaluation and management CPT coding guidelines were revised in 2021, documentation has shifted to emphasize medical decision making (MDM) or total encounter time rather than extensive history and physical exam content.
Cigna’s policy reflects the need to align payer adjudication with these modernized AMA standards.
By enforcing these updated coding principles, Cigna aims to:
- Reduce instances of overbilling or unjustified high-level code use.
- Encourage providers to adhere strictly to current MDM and time-based coding criteria.
- Foster more consistent and transparent claims processing.
- Protect the sustainability of healthcare payments across the network.
This initiative follows a national trend as payers nationwide seek to ensure that reimbursement accurately reflects documented patient care complexity.
Key CPT Codes Affected
| CPT Code | Description | Common Use |
|---|---|---|
| 99204 | New patient, moderate complexity | New patient office visits |
| 99205 | New patient, high complexity | New patient office visits |
| 99214 | Established patient, moderate complexity | Established patient visits |
| 99215 | Established patient, high complexity | Established patient visits |
| 99244 | Office consultation, moderate complexity | Specialist consults |
| 99245 | Office consultation, high complexity | Specialist consults |
Providers billing these codes should pay close attention to documentation practices and claim submission accuracy to avoid denials or payment reductions.
How This Policy Affects Your Practice
The new Cigna policy brings several key implications for healthcare practices:
- Heightened claim review: Expect more rigorous scrutiny of high-level E/M claims.
- Potential payment reduction: Documentation that does not meet AMA guidelines may trigger downcoding.
- Administrative effort: Providers will need to monitor remittance advices carefully and be ready to appeal or provide additional documentation.
- Revenue impact: For many practices, inaccurate or insufficient documentation could mean significant financial losses.
Practices relying on expert medical billing teams or advanced Healthcare Revenue Cycle Management Services will be at an advantage.
These resources help ensure claims are coded correctly the first time and support providers in managing denials and appeals efficiently.
How to Avoid E/M Downcoding with Cigna
1. Follow AMA E/M Guidelines Closely
The cornerstone of avoiding downcoding is precise, guideline-compliant documentation. Use the 2021 AMA E/M coding criteria, which are based on two coding methods:
- Medical Decision Making (MDM): Degree of complexity in diagnosing and managing patient issues.
- Total Time: Inclusive of all time spent on the date of service related to the patient encounter, before, during, and after the visit.
2. Enhance Documentation for MDM
Ensure thorough documentation of:
- The number and complexity of problems addressed.
- The amount and complexity of data reviewed or ordered, such as labs, imaging, and external records.
- The risk level associated with patient management decisions.
Clear, detailed notes that describe clinical reasoning, changes in treatment, diagnostic processes, and referrals strengthen coding support.
3. Document Time Accurately for Time-Based Coding
If using time as the coding basis, document:
- Total time spent preparing to evaluate the patient.
- Face-to-face and non-face-to-face encounters.
- Counseling, coordination, test interpretation, and documentation activities.
Exclude unrelated conversations, travel, or tasks billed separately to meet AMA-defined time coding rules.
4. Monitor Claims and Remittance Advice
Regular review of explanation of benefits (EOBs) and remittance advice helps catch downcoding early. Pay attention to informational codes such as:
- CO150 (information does not support level of service).
- M85 (subjected to review).
- N610 (payment based on level of care).
- CARC 186 (level of care change adjustment).
These codes signal a possible downcode and allow you to take timely corrective steps.
5. Set Up Efficient Internal Audits and Reporting
Work with your electronic health record (EHR) or practice management system (PMS) vendor to generate denial or adjustment reports.
This assists in identifying patterns and high-risk claims for closer scrutiny.
6. Prepare to Appeal When Necessary
If a claim is downcoded incorrectly, appeal quickly with supporting clinical documentation aligned to AMA and CMS coding standards.
Cigna facilitates appeals via a secure fax number, encouraging providers to submit full medical records validating the billed code.
A well-prepared appeal should include:
- Patient and claim identification.
- Submitted versus adjusted codes and payment.
- Details explaining why the higher level is justified.
- Applicable contract or policy references.
- Relevant clinical notes highlighting assessment and decision-making.
Real-Life Scenario: Avoiding Downcoding
Imagine a primary care provider managing a 77-year-old patient with severe COPD, recent weight loss, and new pulmonary symptoms.
After thorough evaluation, diagnostic tests, and medication adjustments, the physician spends 28 minutes and documents complex decision-making.
If downcoding occurs - reducing from CPT 99215 to a 99213 level due to insufficient documentation - a significant revenue loss results despite the higher level of care delivered.
This illustrates the need for comprehensive, guideline-based documentation and vigilance in claim submission and payment review.
How Human Medical Billing Supports You
Partnering with Human medical billing empowers practices to navigate these challenges effectively. Our expert team offers:
- Full-service Healthcare Revenue Cycle Management Services to optimize revenue flow.
- AI medical billing solutions to enhance coding accuracy and reduce errors.
- Denial management services that expedite appeals and recover lost payments.
- Medical credentialing services that ensure provider profiles are up-to-date.
- Medical coding and accounts receivable services to maintain consistent cash flow.
Leverage our experience to keep your practice compliant, financially stable, and focused on patient care rather than billing burdens.
Aligning with Industry Standards and Medical Societies
National medical organizations encourage payers to:
- Target downcoding efforts only at true outlier providers.
- Avoid blanket downcoding policies harming all providers indiscriminately.
- Conduct medical record review before payment adjustment.
- Provide advance notice of potential downcoding programs.
- Communicate clearly with providers on downcoding reasons and appeal options.
The American Medical Association (AMA) opposes automatic or algorithm-driven downcoding without adequate clinical review and provider notification to prevent undue administrative burdens.
Frequently Asked Questions
This practice is common. Providers must review payment levels compared to expected reimbursement and monitor remittance advice carefully to detect downcoding.
No. Only time directly related to patient care activities—such as exam, counseling, documentation, and care coordination—can be counted.
Physicians who frequently bill high-level E/M codes, manage complex patients, or have incomplete documentation are at greatest risk.
Preparing for Cigna’s Policy: Next Steps
- Train providers and staff on updated AMA E/M documentation standards.
- Conduct internal coding audits to check compliance.
- Collaborate with trusted medical billing and coding specialists.
- Implement regular monitoring of claims and remittance advice.
- Develop clear workflows for timely appeals and documentation submission.
Conclusion
Cigna’s new E/M downcoding reimbursement policy marks an important shift toward tighter claims review and documentation expectations starting October 2025.
To protect practice revenue and reduce administrative challenges, providers must embrace meticulous documentation aligned with AMA guidelines, strengthen internal auditing, and leverage expert billing partners.
By preparing now and adopting best practices, healthcare providers can continue to receive appropriate payment for delivering high-quality, complex care.
Contact Human medical billing to learn how our comprehensive Healthcare Revenue Cycle Management Services and AI medical billing can help your practice thrive in this evolving environment.
