Changes are coming to Cigna’s code review policy practices, and these changes will impact allergists.
Cigna Healthcare will begin downcoding certain high-level evaluation and management (E/M) claims by one level starting Oct. 1, 2025. This policy will focus on CPT codes 99204-99205, 99214-99215, and 99244-99245.
Cigna’s announcement suggests that it will downcode certain high-level E/M codes without reviewing the patient’s medical record. Practices would then be able to appeal the downcoding decision by faxing Cigna the patient’s medical record.
Under the new policy, Cigna will review claims and will remove “compliant” physicians whose claims consistently meet coding guidelines from this downcoding program.
Clinicians who disagree with a reimbursement adjustment can submit a reconsideration request by sending the full encounter documentation to Cigna’s secure fax number (833.392.2092). If the initial decision is upheld, administrative appeal rights are available. For detailed information, providers should visit the Evaluation and Management Coding Accuracy (R49) reimbursement policy on the Cigna for Health Care Professionals portal at CignaforHCP.com.
This follows a broader theme of tighter review policies for higher-level E/M services emerging across payers.
For example, Humana’s Medicare Advantage Payment Policy reviews high-level E/M codes across multiple service categories, including outpatient visits, consultations, emergency department services, and home health visits. Similarly, Aetna’s Claim and Code Review Program (CCRP), effective July 2024, focuses on physician and facility claims involving emergency room and other high-level E/M codes. Aetna reviews whether documentation and coding practices justify Level 4 and 5 E/M billing and adjusts claims when the submitted level exceeds supported clinical criteria.
These strategies by payers create administrative burdens that divert allergists’ resources to administrative tasks instead of patient care. We encourage members to partner with their state societies to oppose these changes. When downcoding occurs, appeal. The College and its Advocacy Council are partnering with other national organizations to oppose these draconian changes.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
