CIGNA E/M Policy Change
Cigna is significantly changing its commercial reimbursement policy for the Evaluation Management Service policy. This change goes into effect on October 1, 2025. “Cigna may adjust the E/M CPT codes 99204-99205, 99214-99215, and 99244-99245 to a single level lower when the encounter criteria on the claim does not support the higher E/M level.” Cigna states in the policy that they are using the documentation guidelines published by the AMA. Providers are also expected to adhere to the ICD-10-CM coding guidelines when identifying a diagnosis for the treatment of a condition.
The problem with this policy is that it does not indicate whether they will reduce the level of E/M service based on the claim submitted or after documentation is submitted to CIGNA and reviewed. It is more important than ever that the diagnosis codes submitted on the claim reflect the complexity of the patient’s condition(s) treated. To support a higher level of E/M service, it is essential to report the diagnosis code to the highest level of specificity and avoid unspecified codes if possible.
E/M services are reported either based on medical decision making or time. Complete and detailed documentation is crucial to support levels 4 and 5. Even though a clinically relevant history and examination are now required, ensure the history contains enough detail to paint a complete picture of the patient’s problem(s).
The components of medical decision making include:
Complexity of problems addressed
Amount and/or complexity of data reviewed/analyzed during the encounter
Risk of complications and/or morbidity or mortality of patient management.
When reporting time, itemize the time spent on specific face-to-face and non-face-to-face activities on the date of the patient encounter.
Example
“This encounter took 45 minutes, including taking a history, performing the examination, reviewing the CT scan, reviewing the PCP’s notes, counseling the patient on his new diagnosis of ____, and documenting in the EHR.”
Conclusion
It is essential to monitor your EOB’s and RAs to ensure you are paid for what you billed for all payors, not just CIGNA. If your E/M levels are reduced, review the documentation, and if the level 4 or 5 you billed is justified, file an appeal.
To review the entire policy: https://static.cigna.com/assets/chcp/secure/pdf/resourceLibrary/clinReimPolsModifiers/R49_Evaluation_and_Management_Coding_Accuracy.pdf
If you have not had a coding audit in the past year, now is the time to have a sample of your higher levels of E/M services reviewed by a professional coding auditor. We are here to help. Contact us to schedule a medical coding audit.