The Centers for Medicare & Medicaid Services, Office of the Inspector General, and other national payers have identified an increasing pattern of E/M services being billed by providers at a higher level than what was actually performed.

Therefore, in an effort to promote accurate and consistent reimbursement and protect customers from potential overbilling, Cigna Healthcare will implement a new Evaluation and Management Coding Accuracy (R49) medical reimbursement policy on October 1, 2025.* This policy will review certain professional claims billed with CPT E/M codes 99204-99205, 99214-99215, and 99244-99245 for billing and coding accuracy.

In alignment with American Medical Association (AMA) E/M services guidelines, services may be adjusted by one level only for providers who our records indicate as having a consistent pattern of coding at a higher E/M level for routine services compared to their peers.

Thoughtful application of this policy

Cigna Healthcare understands and appreciates that the vast majority of providers bill E/M claims appropriately and in accordance with AMA billing guidelines. Based on our initial analysis:

• Almost 99 percent of all in-network providers will not be affected by this policy upon implementation.
• This includes more than 97 percent of providers who regularly bill level 4 and 5 E/M codes.

For the approximately three percent of providers who our records indicate as having a consistent pattern of coding at a higher E/M level for routine services compared to their peers, this new reimbursement policy will not automatically result in an adjustment of reimbursement for all claims. Instead, adjustments will be applied only to individual claim lines where the billing information does not substantiate the reported service level.

Methodology to identify affected providers and claims

To identify the small number of providers who may be affected by this policy update, Cigna Healthcare took a conservative approach and focused 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.

When reviewing individual claims, this reimbursement policy utilizes claim-based criteria as a screening mechanism to detect potential discrepancies between the expected and actual levels billed, examining relevant claim data, associated diagnoses, and any additional services rendered during the same encounter.

Determining if a claim has been adjusted and how to request reconsideration

Rather than delaying payment and requesting supporting documentation for the billed code upon receipt of the claim, Cigna Healthcare will issue payment promptly for the lower-level adjusted code, clearly indicating on the explanation of payment (EOP) if a service was adjusted to be reimbursed at a lower level.

As the EOP will also indicate, providers who believe their clinical documentation supports reimbursement for the originally submitted level for the E/M service can submit the customer’s full record of the encounter by paper or digitally to the secure Cigna Healthcarefax number 833.392.2092. If the record supports the original level of coding, the claim will be reimbursed at the original level billed. If the initial determination is upheld, the provider also has the right to an administrative appeal of the decision.

We are confident that this approach substantially reduces administrative burdens, facilitates prompt payment, and safeguards patients from being adversely affected by claim denials.

How to request a bypass from the policy

Additionally, providers who have experienced five or more adjusted claims and believe they are billing in alignment with AMA guidelines may 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 the review substantiates that at least 80 percent of the adjusted claims for E/M services were billed appropriately, their bypass request will be granted. 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.

Additional information

For more information, please view the Evaluation and Management Coding Accuracy (R49) reimbursement policy on the Cigna for Health Care Professionals portal (CignaforHCP.com) or view our frequently asked questions.

Please note that you must log in to access the policy. If you are not a registered user, go to CignaforHCP.com and click Register.

* Please note this policy update does not affect Evernorth Behavioral Health claims.