The ACR recently led a rheumatology community letter to Cigna opposing the payer’s decision to downcode level 4 and 5 evaluation and management (E/M) claims.
Effective Oct. 1, 2025, Cigna implemented a new policy, Evaluation and Management Coding and Accuracy. Claims billed with Current Procedural Terminology (CPT) E/M codes 99204–99205, 99214–99215 and 99244–99245 are subject to additional scrutiny and may be adjusted to a single level lower.
The letter to Cigna, which was co-signed by 27 organizations, highlights the potential harm to rheumatology practices and patients and advocates for recission of the policy. It cautions that inappropriate reimbursement cuts will undermine patients’ timely access to care.
The ACR opposes the inappropriate reduction of payment for rheumatology services and increased administrative burden for practices to appeal these downcoded claims. Additionally, the ACR is concerned about the growing use of artificial intelligence for claims review and implores payers to ensure integrity in claims processing by employing professional coders.
To help avoid inappropriate downcoding, ACR members are encouraged to code and bill the highest level of specificity for diagnoses and ensure proper documentation in the medical record. Providers are cautioned to avoid the overuse of unspecified ICD-10 codes and to ensure adequate documentation to support medical necessity and the level of service billed.
For more information about Cigna downcoding or to request assistance with other practice or insurance issues, contact [email protected].
