Fam Pract Manag. 2025;32(6):5-6
The publication of this content is funded by the American Academy of Family Physicians. Journal editors were not involved in the development of this content.
A key priority for the American Academy of Family Physicians (AAFP) is to improve primary care payment while reducing the administrative burdens associated with getting paid. To advance these goals, the AAFP advocates across multiple channels, including actively monitoring and responding to public and private payer policies, especially those that negatively impact primary care practices. In addition to addressing specific payer actions, the AAFP engages in broader advocacy efforts through ongoing dialogue with national stakeholders, participating in coalitions focused on payment reform, and developing tools and resources to support chapters and members in their local efforts.
In recent years, several major commerical payers have implemented policies that automatically lower the E/M code, resulting in lower payments based solely on the diagnosis on the claim submission. Most recently, Cigna Healthcare announced its new Evaluation and Management (E/M) Coding and Accuracy (R49) policy (effective October 1, 2025), which will permit automatic downcoding of E/M claims without reviewing the supporting clinical documentation.1 The policy states, “Cigna may adjust the E/M CPT® code 99204-99205, 99214-99215, 99244-99245 to a single level lower when the encounter criteria on the claim does not support the higher level E/M CPT® code reported.” Note: Just prior to the publication of this article, Cigna paused their downcoding policy in the state of California.
The AAFP strongly opposes downcoding policies, arguing that this approach ignores CPT guidance which allows office/outpatient E/M coding based on either medical decision-making (MDM) or total time spent on the date of service—factors that cannot be determined from diagnosis codes alone.
CPT GUIDANCE
E/M CPT code set and reporting guidelines clearly indicate that documentation from the medical record is needed to determine if the level of MDM or total time spent on the date of the encounter has been correctly coded.2 This cannot be determined by the primary diagnosis on the claim alone.
CPT guidance states, “The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition.”3
WHY IT MATTERS FOR FAMILY PHYSICIANS
Family physicians regularly manage multiple chronic conditions, coordinate care with specialists, address behavioral health and account for social drivers of health—all within the span of a single patient visit. Diagnosis codes do not capture these complexities and cannot be fairly judged by algorithms or claims encounter criteria.
The AAFP warns that automatic downcoding risks:
Undervaluing the complexity of family medicine
Increasing administrative burden through appeals
Straining small and independent practices financially, particularly in rural and underserved areas
Eroding trust by implying that physicians who code higher-level visits are engaging in fraudulent behavior
Encouraging inappropriate undercoding, which fails to capture the complexity of care accurately
AAFP RECOMMENDATIONS TO PAYERS
The Academy is urging all payers, but especially those who have established downcoding policies and procedures, to:
Pay claims as submitted unless a clear, documented rationale exists to do otherwise.
Clearly and proactively communicate the program's parameters. Notify physicians when they are identified as outliers, including a description of the data used and the reasons why, before adjusting individual claims. Offer these physicians additional education.
Streamline appeals and determination processes with an easy-to-use appeals process, making determinations in a timely manner and providing detailed information on the remittance advice if an appeal is denied.
Identify a pathway for being removed from the program. Equip physicians with a clear understanding of the changes or improvements necessary to no longer be considered an outlier and thus removed from the program.
Disclose the use of artificial intelligence (AI), algorithms and analytic solutions. In accordance with the AAFP's Ethical Application of Artificial Intelligence in Family Medicine policy, we urge payers to transparently communicate their methods for executing this program to their in-network physicians and practice managers to offer assurances that determinations are being appropriately made.
The AAFP has also raised these concerns directly with Cigna and the insurer advocacy group AHIP (formerly America's Health Insurance Plans), urging them to promote consistency and transparency in downcoding policies across their member plans.4 In a formal letter, the AAFP called on AHIP to encourage proactive communication with physicians, streamline appeals processes and disclose the use of AI in payment determinations. The AAFP emphasized that automatic downcoding undermines the complexity of care provided by family physicians. This presumption is likely to lead to inappropriate undercoding, which fails to accurately capture the complexity of care and the resources required to meet patients' needs.
PROTECTING PRIMARY CARE'S VALUES
The AAFP emphasizes that inappropriate downcoding policies could disproportionately harm family physicians, whose practices rely heavily on E/M services. With the United States facing rising rates of chronic disease, the AAFP argues that strong primary care is foundational and critical for both improving patient outcomes and reducing health care costs.
As part of our ongoing advocacy efforts, the AAFP has offered to collaborate with AHIP, Cigna and other payers on educational outreach rather than use punitive payment cuts. Additionally, the AAFP recently conducted our annual Payer Engagement and Alignment Survey to assess the degree to which payer behavior aligns with AAFP policies and positions across the following five key domains5:
Reducing administrative burden
Limiting performance measurement
Increasing primary care investment and encouraging value-based care progress
Supporting advanced primary care and population health capabilities
Protecting physicians' autonomy and scope of practice
Results of the survey inform our ongoing payer engagement strategy and advocacy priorities. The Academy remains committed to ensuring that family physicians are resourced and compensated fairly to provide high-quality, comprehensive care in every community.
STATE CHAPTER ADVOCACY
For those who would like to directly engage with payers in their markets on the issue of downcoding, the AAFP has equipped state chapters with a customizable template letter to support your advocacy against downcoding policies of state and regional health plans. Visit our E/M coding webpage to access a customizable template letter for opposing downcoding by health plans. You'll also find answers to common coding questions there as well.
