Cigna’s downcoding policy gets pushback from physician groups

Editor's note: Cigna has paused this policy in California after the California Medical Association sent an inquiry to state regulators about its legality there.

A Cigna plan to downcode certain E/M visits is drawing opposition from physician groups, including the American Academy of Family Physicians (AAFP). Beginning Oct. 1, Cigna will launch a new “Evaluation and Management Coding Accuracy” policy (R49) that downcodes visits reported with 99204-99205, 99214-99215, and 99244-99245 when the insurer believes a physician consistently uses them for visits where the primary diagnosis and other claim-based criteria do not indicate that level of E/M. Two example diagnoses Cigna gives are “earache” and “sore throat.”  

The AAFP raised concerns about this approach in letters to both Cigna and the insurer advocacy group AHIP (formerly America’s Health Insurance Plans). The letters emphasize CPT rules that state medical record documentation is needed to determine if the level of an E/M visit has been correctly coded based on total time or medical decision making — the primary diagnosis on a claim is not sufficient. In addition, automatic downcoding policies based on diagnosis alone fail to reflect the continuity and complexity of care family physicians provide, which often includes managing multiple chronic conditions, coordinating with specialists, addressing behavioral health needs, and considering social drivers of health, all within a single visit.  

The AAFP urged Cigna to take a proactive, comprehensive, educational approach to addressing concerns relative to the coding practices of family physicians and welcomed the opportunity to collaborate with them on educational outreach initiatives. 

What this means for your practice

In response to Cigna's policy change, practices should take the following steps:

• Review clinical documentation practices: Ensure that records clearly justify the level of service billed to payers through regular internal review.

• Check claims information after submission: Determine if your claims are being downcoded by reviewing the explanation of benefits.   

• Challenge individual claim reductions: Submit supporting documentation quickly to contest downcoded claims. Monitor for recurring trends that may indicate broader systemic issues. Documentation should be faxed to 833-392-2092.

Cigna says they expect almost 99% of all in-network clinicians will remain unaffected by this policy when it is first implemented, including more than 97% of those who bill level 4 and 5 E/M codes.

According to Cigna’s program FAQs, physicians who experience five or more downcoded claims and believe they are billing in alignment with American Medical Association (AMA) guidelines may request to bypass the policy by emailing  EMCodingAccuracy@CignaHealthcare.com. Cigna Healthcare will then review clinical documentation for a subset of the physician’s claim history. If the review substantiates that at least 80% of the adjusted claims for E/M services were billed appropriately, the bypass request will be granted. The clinician’s continued exclusion from 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.

Supporting documents

• AAFP Coding for Evaluation and Management Services: Answer to Common Questions
• AAFP Coding and Payment policy
• AMA payer downcoding resource with tips for documenting and defending E/M services.

— Brennan Cantrell, AAFP Senior Strategist, Market Transformation

Posted on Sept. 16, 2025