Effective October 1, 2025, Cigna Healthcare (Cigna) boldly enacted its “Evaluation and Management Coding and Accuracy Reimbursement Policy” which could be in violation of some state’s insurance laws and more importantly, is inconsistent with the updated 2023 Evaluation and Management (E/M) Guidelines developed by the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS).
Cigna maintains that CMS, the Office of the Inspector General (OIG), and other national payers have identified an increasing pattern of E/M services being billed by providers at a higher level than what was performed. Therefore, to promote accurate and consistent reimbursement and protect customers from potential overbilling, they are implementing this policy.[1]
The following provision from this policy is fueling consternation for practitioners: “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.” (Emphasis added by SunStone).
While the Cigna policy does not explicitly state what encounter criteria on the claim will be used to down code an E/M service, a related Cigna FAQ reveals it may be the claim diagnoses:
“Cigna Healthcare took a conservative approach and reviewed claims over a 12-month period, with a focus on providers who consistently billed diagnosis codes and higher-level E/M codes not typically associated with complex cases requiring additional decision-making time. For example, diagnoses such as “earache” or “sore throat” generally do not justify the use of high-level decision-making codes. Providers who regularly billed such diagnoses at elevated levels relative to their peers were identified for potential inclusion under this policy.”
Cigna plans to down code the E/M level on the claim, pay the applicable amount and then, according to their policy:
“When a code level has been adjusted and, subsequently, medical records are submitted that substantiate the complexity and the Medical Decision Making (MDM) or time associated with the reported E/M CPT® code level, the code will be reimbursed at the level initially submitted.”[2]
Professional Organizations Push Back
The California Medical Association (CMA) has reported that during its inquiry to state regulators regarding the legality of Cigna’s new policy, a Cigna representative indicated that implementation in California would be paused pending review by the Department of Managed Health Care (DMHC).
CMA cautioned that the policy appears to violate state law, is inconsistent with nationally recognized coding standards, and functions as a barrier to appropriate reimbursement and patient care.[3] At this time, CMA’s statement is the only source referencing a pause in California and SunStone is seeking confirmation from Cigna and clarification on whether the pause applies nationwide.
In addition to the CMA, the AMA, and other state professional organizations, including the Medical Society of the State of New York (MSSNY) and the Texas Medical Association (TMA), all expressed concerns to Cigna as follows:
The policy does not address the methodology used to determine which physicians claims will be selected; the MSSNY for example, indicated to Cigna that New York Public Health Law section 4406-d and Insurance Law Section 4893 detail how profiling data is to be gathered and health professionals informed when such data will be used to evaluate their performance or practice.[4]
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.[5]
An automated down coding of an E/M claim without review of the medical record undermines the integrity of the E/M coding and denies fair payment for the work involved in caring for complex patients.[6]
The policy overlooks the fact that an E/M service is a cognitive service involving the documentation of clinical reasoning and decisions made regarding treatment options.
Cigna’s approach conflicts with the AMA and CMS guidelines which state that an E/M level is assigned based on the complexity of the MDM or total time and not diagnosis alone.
Automatic downcoding programs place onerous administrative burdens on practices to fight for appropriate payment rates in an increasingly challenging environment for small and independent physician practices.[7]
SunStone adds an additional talking point regarding the disconnect between Cigna’s new policy and CMS’ recent efforts to acknowledge and increase payment for the inherent complexity of care rendered by physicians across all medical specialties who may be serving as the patient’s principal provider of care. Effective January 1, 2024, CMS enacted the visit complexity add-on HCPCS code G2211. All medical professionals who can bill office and outpatient (O/O) E/M visits (CPT codes 99202-99205, 99211-99215), regardless of specialty, may use the code with O/O E/M visits of any level when they serve as the continuing focal point for all patient’s health care service needs or provide ongoing care for a single serious condition. The G2211 code is not restricted to medical professionals based on specialties.[8]
What Providers Can Do Now
SunStone offers the following suggested actions to consider if not already underway:
Engage with your organizational internal counsel to ensure they are aware of Cigna’s policy change as it may be in violation of state insurance laws.
Review current contracts with Cigna to determine if there are any contractual violations inherent in Cigna’s new policy.
Conduct internal profiling of all health care practitioners billing E/M services to determine if there are any outliers consistently billing higher level E/M codes and conduct a probe sample of their medical records to determine if their documentation supports the level of E/M billed.
Request a Comparative Billing Report (CBR) from your respective Medicare Administrative Contractor (MAC) to determine how your organizational practitioners compare with the state’s utilization of E/M codes to the nation by specialty.
Implement a comprehensive policy to formerly appeal any down-coded claims. Hopefully, Cigna will rescind this new policy, but should you begin to see E/M claims automatically down coded one level, please feel free to contact us for a sample letter to use for the appeal process.
Still have questions or need help evaluating how Cigna's policy may impact your facility?
SunStone offers services specifically geared toward contract management solutions, denial analysis and appeals, as well as templates to assist providers navigate the new requirements to achieve maximum revenue capture. Please contact:
Vonda Moon, Senior Principal at vondamoon@sunstoneconsulting.com
Joli Fitzgibbons, Senior Director at jolifitzgibbons@sunstoneconsulting.com
[1] Cigna Healthcare, Provider Newsroom. “New Reimbursement Policy for Evaluation and Management Services Claims effective October 1, 2025.” September 9, 2025.https://providernewsroom.com/cigna-healthcare/new-reimbursement-policy-for-professional-evaluation-and-management-services-claims-effective-october-1-2025/
[2] Cigna Healthcare, Evaluation and Management Coding and Accuracy Policy. Effective date 10/01/2025.
[3] CMA. Newsroom; “Cigna Agrees to Pause Controversial Downcoding Policy,” October 1, 2025. https://www.cmadocs.org/newsroom/news/view/ArticleId/50993/Cigna-agrees-to-pause-controversial-downcoding-policy
[4] MSSNY letter to Cigna Healthcare, September 19, 2025.
[5] AMA letter to Cigna Healthcare, August 28, 2025.
[6] CMA “Talking Points” publication for providers, February 3, 2025.
[7] TMA letter to Cigna Healthcare, July 30, 2025.
[8] CMS. Medicare Learning Network (MLN), MM13473.