Starting October 1, 2025, Cigna began to adjust certain higher-level evaluation and management (E/M) codes to a lower level – a practice also known as downcoding. Downcoding occurs when the payer determines the encounter criteria in the claim does not rise to the complexity required for the E/M code in the submitted claim. Cigna’s policy will apply to codes 99204-99205; 99214-99215; and 99244-99245, which represent professional claims for level 4 and 5 E/M services and indicate moderate or high-level complexity visits for new and established patients.

In a letter to Cigna, MSMS urged the payer to rescind the policy. Regarding MSMS’s opposition to this new policy, MSMS President Amit Ghose, MD, stated the following:

“We request that Cigna immediately rescind this policy, as it conflicts with current E/M coding guidelines and threatens our physician members with unfair, unwarranted payment reductions at a time when physicians face unprecedented financial challenges. This approach creates unnecessary friction with physician practices, undermines trust between providers and health plans, and makes it even more difficult to deliver high-quality care in an already resource-limited environment.”

Cigna maintains the policy is intended to place additional scrutiny only on claims billed by providers their records indicate as having a consistent pattern of coding at a higher E/M level compared to their peers. They have indicated that they will identify which physicians will continue to undergo the downcoding policy based on a review of claims submitted over a 12-month period, with a focus on those who consistently bill diagnosis codes and higher-level E/M codes not typically associated with complex cases requiring additional decision-making time.

Next steps for physicians: MSMS encourages physicians and medical groups to continue voicing their concerns until the policy is formally withdrawn. When contacting Cigna, physicians should emphasize that:

• The policy lacks transparency and fails to disclose claims adjudication criteria.
• It conflicts with AMA and CMS E/M coding guidelines.
• It will increase administrative burdens and costs for both practices and the insurer.

Please contact Cigna Customer Service at 1-800-88-CIGNA (+1-800-882-4462) or via the provider portal and request that the company rescind the R49 downcoding policy.