Cigna’s new E/M downcoding policy — which will apply to certain high-level E/M claims — takes effect next week. And as the Oct. 1 implementation date approaches, the payer has finally responded to questions that have been swirling about the new policy.

Check out three facts that can help you prepare for the new E/M downcoding possibilities.

1. Cigna Is Identifying Providers Based on Previous Claims History

Under its new policy, Cigna will review claims reported with E/M codes 99204-99205, 99214-99215, and 99244-99245 for accuracy, and will downcode them by one level if the services don’t meet the AMA guidelines for these high-level codes. But many practices have wondered exactly what these “reviews” will encompass.

Cigna has revealed its new process for downcoding such claims. The payer has reviewed claims over a previous one-year period to identify providers that reported high-level E/M codes with diagnoses “not typically associated with complex cases requiring additional decision-making time,” Cigna says in its new FAQs, published earlier in September.

For instance, if you regularly report 99205 for patients with earaches, Cigna is likely including you in its new E/M downcoding policy. However, Cigna explained, “If a provider is impacted by the policy, it does not mean that reimbursement for all of their claims with level 4 and 5 CPT E/M codes will be adjusted. Each claim will be individually reviewed for coding accuracy.”

Cigna will use claim-based criteria for initial screenings to identify potential discrepancies, “examining relevant claim data, associated diagnoses, and any additional services rendered during the same encounter,” Cigna said. “We do not rely exclusively on algorithms to make final determinations.”

2. Cigna Isn’t Requesting Documentation

If your claim is subject to E/M downcoding edits, Cigna won’t necessarily request your documentation. The payer says that since fewer than 3.5% of claims will be subject to this new policy, it aims to keep things simple by not requesting documentation.

However, if your claims are downcoded, you can request reconsideration, at which point you’d submit your documentation and a certified coder would review it, the payer says.

3. Certain Claims Won’t Be Subject to Scrutiny

Not every type of claim will be subject to the E/M downcoding policy, Cigna said. Exclusions from the policy include claims for cancer, transplants, and treatment of children under the age of one.