Beginning October 1, 2025, Cigna will implement a new Evaluation and Management (E/M) reimbursement policy (Policy R49) that allows for the automatic downcoding of high-level E/M services. If the documentation submitted with a claim doesn’t support the level billed, Cigna may reduce the payment to a lower-level code.
In this article, we’ll explain which E/M codes are affected, why the policy is changing, and how providers can protect their revenue by following proper coding and documentation guidelines.
NOTE: SEE LATEST UPDATE ON THIS TOPIC AS OF 10/8/2025 HERE: Cigna Policy Temporary Pause
Which E/M Codes Are Affected?
Cigna’s new reimbursement policy applies to the following CPT® codes and may result in the level being downgraded by one step if medical necessity and documentation don’t support the level billed:
– 99204 → 99203
– 99205 → 99204
– 99214 → 99213
– 99215 → 99214
– 99244 → 99243
– 99245 → 99244
Why Is Cigna Implementing This Change?
Cigna’s decision is driven by a growing trend across payers and regulatory bodies like CMS and the OIG: increased scrutiny of high-level E/M billing. National data shows a rise in reporting higher-level codes, which has triggered concerns about inconsistent documentation and upcoding.
This policy mirrors CMS’s stance that E/M levels must reflect actual complexity—either by medical decision making (MDM) or total time spent on the date of the encounter.
How to Choose the Correct E/M Code
Providers should select E/M codes based on either:
- Medical Decision Making (MDM): Considers the number and complexity of problems, data reviewed, and risk of patient management.
- Total Time: Includes only the time personally spent by the provider on the encounter date, such as reviewing results, counseling, and documentation. Time spent on separately billable procedures, staff activities, or patient wait time should not be included.
What Happens If a Code Is Downcoded?
If Cigna determines that a submitted E/M code isn’t supported, they will reimburse it at the next lower level. However, providers may submit medical records to appeal the decision. If the documentation clearly supports the original level, Cigna may adjust the payment upward.
Best Practices for E/M Documentation and Coding Compliance
- Conduct regular internal audits for high-level E/M codes (99204–99205, 99214–99215.
- Educate your providers on updated E/M coding guidelines for MDM and time.
- Use templates carefully—ensure they’re tailored to the visit and not overly templated or cloned.
- Document procedures separately from E/M when both are billed on the same day.
- Include a time statement if selecting a code based on total time.
StreamlineMD Is Here to Help
Cigna’s policy change signals a tightening landscape across all payers when it comes to documentation and E/M billing integrity. Documentation is now more than ever under the microscope. If the complexity isn’t supported, payment will be reduced. This is not just about getting paid — it’s about avoiding audits, claw-backs, and reputational risk.
At StreamlineMD, we help Vascular and Interventional Radiology practices maintain compliant and accurate coding practices. We are committed to assisting providers in staying E/M educated and compliant. If you’d like to schedule an E/M documentation training or receive a tailored audit of your high-level E/M use, don’t hesitate to get in touch with our coding compliance team.
By Candice Chandler, CPC, CEMC
Manager, StreamlineMD Coding Department
StreamlineMD provides Revenue Cycle Solutions to Radiology & Interventional Specialists. Our Mission is to Improve Healthcare for All Americans. Our Core Values that guide us on our mission are Service Quality, Teamwork, Accountability, Efficiency, Adaptability, Communication, and Integrity. Proud winner of the Great Place To Work award. Learn more about us at streamlineMD.com.
