Starting October 1, 2025, Cigna Healthcare® will implement a sweeping new reimbursement policy that could directly impact how physicians are paid. Under the Evaluation and Management Coding Accuracy Policy (R49), Cigna will begin reviewing select professional claims for billing and documentation accuracy, with payment levels subject to reduction — even without prior notification.
If you’re a provider billing E/M codes 99204–99205, 99214–99215, or 99244–99245, this policy demands your immediate attention.
What is Changing?
Cigna’s new policy allows them to downgrade E/M code levels by one level if your documentation does not meet AMA’s Evaluation and Management guidelines — regardless of the care you actually provided. This can result in lower reimbursement, with no advance warning.
The impacted codes include:
- New patient visits: 99204 – 99205
- Established patient visits: 99214 – 99215
- Consultations: 99244 – 99245
Reconsideration Options: Can You Fight It?
Yes — but it’s up to you to act fast.
If you disagree with Cigna’s downgrade, you must:
- Submit full medical record documentation of the patient encounter.
- Fax it to 833-392-2092 for reconsideration.
- If successful, the claim will be readjusted and a new Explanation of Payment (EOP) will be issued.
If not, you still retain your appeal rights — but that means more administrative work and delays in payment.
Final Thoughts for Physicians
This policy is a clear signal that Cigna is intensifying its scrutiny of physician billing — and your documentation is now under the microscope.
To avoid financial penalties:
- Train staff on updated AMA E/M coding
- Audit documentation practices
- Ensure every level of service is fully supported
Have a process in place to challenge these denials. Every dollar counts. If your practice needs assistance reach out – we handle appeals on a contingency basis.
