Frequently asked questions | For Health care providers

Cigna Healthcare^® will implement a new reimbursement policy, Evaluation and Management Coding Accuracy (R49), to review professional claims billed with Current Procedural Terminology (CPT^®) evaluation and management (E/M) codes 99204-99205, 99214-99215, and 99244-99245. This policy aims to ensure billing and coding accuracy in alignment with American Medical Association (AMA) E/M services guidelines.

Questions and answers

1. What’s happening?
   • Effective for dates of service on or after October 1, 2025, reimbursement for certain services and for certain providers may be adjusted by one level to reflect the appropriate reimbursement when the AMA guidelines are not met.
2. Why is this change being made?
   • The Centers for Medicare & Medicaid Services (CMS), Office of the Inspector General, and other national payers have identified an increasing pattern of E/M services being billed at a higher level than what was performed.
   • We are making this update to address these discrepancies by appropriately categorizing E/M services through alignment with AMA guidelines and the implementation of a coding accuracy program for the affected CPT E/M codes. Our policy is consistent with, if not less stringent than, similar policies established by competitor health plans. 
3. Will this reimbursement policy be applied unilaterally?
   • No. Cigna Healthcare understands and appreciates that the vast majority of providers bill E/M claims consistently with their peers and within AMA billing guidelines. That is why, per our initial analysis, we expect almost 99 percent of all in-network providers will remain unaffected by this policy when it is first implemented, including more than 97 percent of providers who bill level 4 and 5 E/M codes.
   • This reimbursement policy will apply only to certain in-network providers for certain professional claims that are billed with CPT E/M codes 99204-99205, 99214-99215, and 99244-99245. Unlike other payers who may implement these programs broadly, Cigna Healthcare will review claims only from providers identified as having a pattern of coding at a higher E/M level.
4. How are effected providers identified?
   • To identify the small number of providers who may be affected by this policy update, Cigna Healthcare took a conservative approach and reviewed claims over a 12-month period, with a focus on providers who consistently billed diagnosis codes and higher-level E/M codes not typically associated with complex cases requiring additional decision-making time.
   • For example, diagnoses such as “earache” or “sore throat” generally do not justify the use of high-level decision-making codes. Providers who regularly billed such diagnoses at elevated levels relative to their peers were identified for potential inclusion under this policy.
   • If a provider is impacted by the policy, it does not mean that reimbursement for all of their claims with level 4 and 5 CPT E/M codes will be adjusted. Each claim will be individually reviewed for coding accuracy.
5. How are claims assessed?
   • This reimbursement policy uses claim-based criteria as an initial screening mechanism to detect potential discrepancies, examining relevant claim data, associated diagnoses, and any additional services rendered during the same encounter. We do not rely exclusively on algorithms to make final determinations.
   • If a code is adjusted, the affected provider always has the right to request reconsideration. Claims submitted for reconsideration will be evaluated by certified coders. This ensures all documents relative to AMA E/M coding guidelines are considered, and a thorough coding review is completed, before a final determination is made.
   • Cigna Healthcare does not use artificial intelligence (AI) to deny coverage or claims. You can read more about our approach to AI here.
6. Why is clinical documentation not immediately required?
   • As the overall claim impact is minimal (less than three and a half percent at the time of implementation), our intent is to minimize the provider’s administrative burden by not requiring clinical documentation to be immediately submitted. If a provider requests reconsideration for a specific claim that was adjusted, or wants to be bypassed from the policy entirely, clinical documentation will be requested.
7. How will areas of higher complexity be evaluated?
   • Cigna Healthcare applied extra consideration to the added complexity that certain visits may entail across various services, age groups, and specialty types. This is taken into account when determining if a provider has a pattern of coding at a higher E/M level compared to peers.
   • In all cases, if a provider submits a claim that they believe was adjusted incorrectly as a result of this reimbursement policy, they can request a reconsideration. Additional details about this process are available below.
   • Please note, certain services will not be subject to adjustment under the policy. This includes claims for cancer, transplants, and treatment of children under the age of one.
8. Will this reimbursement policy lead to denied claims?
   • No. This reimbursement policy will not lead to claims being pended or denied, or delay patient care in any way. Rather than delaying payment and requesting supporting documentation for the billed code upon receipt of the claim, Cigna Healthcare will be issuing payment promptly for the lower-level adjusted code. We are confident that this approach substantially reduces administrative burdens, facilitates prompt payment, and safeguards patients from being adversely affected by claim denials.
9. Can a reconsideration request be submitted?
   • Yes. Once this reimbursement policy takes effect, providers who believe their clinical documentation supports reimbursement for the originally submitted level for the E/M service should submit the customer’s full record of the encounter to the secure Cigna Healthcare fax number 833.392.2092 for prompt review. If the clinical documentation substantiate that the original codes were accurate as submitted, claims will be adjusted, and an updated explanation of payment will be issued.
   • Administrative appeal rights are available if the original determination is upheld.
10. Can a provider request a bypass from this reimbursement policy?
    • Yes. Once this reimbursement policy takes effect, providers who have experienced at least five adjusted claims, and believe they are billing in alignment with AMA guidelines, can request to have their claims bypassed from the policy by emailing EMCodingAccuracy@CignaHealthcare.com.
    • Cigna Healthcare will request clinical documentation for a subset of the provider’s claim history for review. If this review substantiates that at least 80 percent of the adjusted claims for E/M services were billed appropriately, their bypass request will be approved. A provider’s continued inclusion in the policy will be determined by their coding patterns and alignment to the AMA E/M services guidelines. Cigna Healthcare will conduct periodic claim reviews to verify compliance. Based on that review, providers may or may not be impacted by the policy. 

Additional information

For more information about the Evaluation and Management Coding Accuracy (R49) reimbursement policy, log in to the Cigna for Health Care Professionals portal (CignaforHCP.com). Registration is required to access this information.