News: New Cigna policy to automatically ‘downcode’ certain E/M codes

Cigna has released a new policy that would automatically reduce payments for level 4 and 5 Evaluation and Management (E/M) claims, effective for dates of service on or after October 1, 2025.

According to HealthLeaders, Cigna can “unilaterally downcode claims by one level if the submitted diagnosis does not appear to support the complexity of the visit.” In order to receive the originally billed payment, providers will now be required to file an appeal to justify the initial coding.

The new policy has drawn criticism from physician advocacy groups who argue that the policy is not only intentionally burdensome to providers, but it’s illegal.

For instance, the Texas Medical Association (TMA), in a letter to Cigna, stated: “Physicians are trained that the medical record is the cornerstone of quality care, documenting their clinical reasoning and reflecting the complexity and appropriateness of care provided.”

Similarly, the California Medical Association (CMA) argued that “Cigna’s policy undermines the integrity of the E/M coding framework and appears inconsistent with AMA and CMS standards — as well as California law that requires health plans to follow nationally recognized guidelines.”

Editor’s note: To read the Cigna policy announcement, click here. To read the HealthLeaders coverage, click here. To read the TMA statement, click here. To read the CMA statement, click here.