Cigna has announced a temporary pause to the implementation of its Evaluation and Management (E/M) Coding and Accuracy Policy (R49), which was initially scheduled to take effect on October 1, 2025. This decision follows significant advocacy from national and state medical associations, including the American Medical Association (AMA), the American College of Allergy, Asthma & Immunology, and the California Medical Association (CMA), as well as ongoing regulatory review by the California Department of Managed Health Care (DMHC).
See previous StreamlineMD blog on this subject: Click Here
Background on Policy R49
The R49 policy would have allowed Cigna to automatically downcode higher-level E/M services when the insurer determined that documentation did not substantiate the billed level of service. In such cases, providers would have been required to appeal the decision and submit medical records—often by fax—creating new layers of administrative work for practices already managing complex compliance and documentation requirements.
Concerns Raised by Physician Organizations
Medical groups across the country expressed deep concern that Cigna’s approach:
- Lacked transparency, as the insurer had not disclosed the specific algorithms or data elements used to determine downcoding.
- Conflicted with nationally recognized coding standards, including those issued by the AMA and CMS.
- Increased administrative burden and costs for practices, particularly in subspecialties like allergy and immunology where complex patient histories justify higher-level visit codes.
- Potentially violated state claims payment and disclosure laws, prompting regulatory scrutiny in California.
Current Status
While Cigna has agreed to pause the policy pending DMHC review, it has not yet announced whether it will entirely rescind or modify R49. The CMA has requested clarification on which Cigna products the pause applies to, and both CMA and AMA continue to advocate for complete withdrawal of the policy.
What Physicians Should Do
Until a formal resolution is announced, StreamlineMD encourages physicians and medical groups to continue engaging with Cigna. Practices may contact Cigna Customer Service at (800) 88-Cigna (882-4462) or through the provider portal to share concerns and request that the insurer permanently withdraw the R49 downcoding policy.
When communicating with Cigna, it is recommended that practices emphasize that the policy:
- Conflicts with AMA and CMS E/M guidelines.
- Lacks transparency regarding claims adjudication criteria.
- Increases administrative costs for both providers and the payer.
- Undermines accurate reimbursement for complex patient encounters.
StreamlineMD’s Commitment
StreamlineMD remains committed to keeping our clients informed of payer policy changes affecting E/M coding, compliance, and reimbursement. We will continue to monitor developments from Cigna and share updates as additional details become available.
Source:
https://college.acaai.org/cigna-pauses-downcoding-policy/
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