If your practice contracts with Cigna Healthcare, you may soon find that your E/M pay is significantly lower than it used to be. Why? Because a new Cigna E/M policy, announced July 1, 2025, pledges to downcode some E/M codes by one level following claim reviews.

Read on to find out how the new Cigna E/M policy will affect your practice’s pay, and how to navigate the change.

What the Cigna E/M Policy Says

Cigna’s new policy says that the company will now review claims reported with E/M codes 99204-99205, 99214-99215, and 99244-99245 “for billing and coding accuracy in alignment with American Medical Association (AMA) E/M services guidelines.” Cigna adds that, “Effective for dates of service on or after October 1, 2025, services may be adjusted by one level to reflect the appropriate reimbursement when the AMA guidelines are not met.”

For example: Suppose you submit a claim billed at 99214. If Cigna determined that the claim doesn’t align with the E/M guidelines, it will only pay you the rate for 99213 — one level lower.

About the reviews: Cigna doesn’t state how frequently it will perform these E/M reviews, but the insurer says they will be performed periodically. “Supporting documentation will be requested should we determine the established guidelines were not followed,” Cigna notes, adding that providers must also adhere to the ICD-10 CM coding guidelines “when identifying a diagnosis for the treatment of a condition.”

The confusing part of the new Cigna E/M policy is that it doesn’t outline the sequence of the new process. Does Cigna plan to review documentation before downcoding the claim or afterward? If the plan is to review the documentation after downcoding, it’s unclear what would warrant a downcode based on a claim review alone and not documentation review.

For instance, would Cigna downcode based on certain procedures being billed with the E/M code? Or E/M levels that reviewers don’t feel are appropriate simply based on the ICD-10-CM code? Or some other reason? This confusion makes it challenging to anticipate how you can prepare for the changes.

Tighten Up Your Coding Processes

The best way to be ready for Cigna’s E/M policy change is to shore up your evaluation and management coding processes. Whether you’re selecting your code level based on medical decision making or time, you should revisit the coding policies that went into effect in 2021. Make sure you understand:

• How to document time spent on an encounter
• The time thresholds that apply to each code level
• How to tally the right number of MDM elements for each code level
• What constitutes a new patient vs. established
• When you can report a separate service with an E/M and when it’s bundled

Train your entire staff on the fundamentals of E/M coding, and provide reminders to providers on how to document properly. The tighter your evaluation and management processes, the better you’ll comply with the Cigna E/M policy.