In early July, Cigna announced a new reimbursement policy, Evaluation and Management Coding and Accuracy (R49), which will become effective on Oct. 1. The policy will subject claims billed with Current Procedural Terminology (CPT) evaluation and management (E/M) codes 99204–99205, 99214–99215 and 99244–99245 to additional scrutiny and may result in some claims being adjusted to one level lower.
The ACR opposes the inappropriate reduction of payment for rheumatology services and the increased administrative burden for practices to appeal these downcoded claims. The ACR Insurance Subcommittee of the Committee on Rheumatologic Care sent a letter to Cigna advocating for rescission of the policy in favor of more measured and appropriate strategies for ensuring claim accuracy. Additionally, ACR recognizes that health insurance payers are increasingly using artificial intelligence to review claims, and we implore these 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 the Cigna downcoding policy or to request assistance with other practice or insurance issues, contact [email protected].