TL;DR: Cigna will start auto-downcoding many high-level visits on Oct 1. Expect more admin work and delayed payment. Here’s what to do and how Thrivory helps.
Starting October 1, many physicians will get paid less for the same work, automatically. Cigna will roll out a new reimbursement policy that auto-downcodes many level 4 and 5 E/M visits. With the new “Evaluation and Management Coding Accuracy” policy (R49), the policy allows Cigna to reduce claims by one level if the information on the claim does not support the complexity you billed. If you want the original payment, you must appeal after the fact and send the whole chart. That’s the rule as written, folks.
Cigna’s press page adds the usual friendly pitch: almost 99% of in-network providers “won’t be affected,” and adjustments will “only” drop a single level, and you can ask for a bypass after you send enough records… unggghh… They even published a fax number like it’s 2003. This hits your most common high-complexity visits, level 4 and 5 office visits and consults (99204-99205, 99214-99215, 99244-99245). Evernorth Behavioral Health claims are excluded…for now.
Physician groups aren’t too happy about it. The California Medical Association and Texas Medical Association say the policy is unlawful, inconsistent with CPT, and guaranteed to bury practices in busywork. HealthLeaders summed it up plainly: automatic downcoding based on what’s on the claim, then a post-payment appeal with full medical records. In practical terms, this could mean more delay and friction for providers.
Why this needs pushback
Diagnosis is not a crystal ball. AMA E/M leveling is based on time or medical decision-making. A “simple” final diagnosis can follow complex work that absolutely qualifies for 99215. Using claim-level criteria as a gatekeeper ignores that reality.
It shifts labor and risk to practices. Cigna pays the lower level upfront and asks you to appeal to get back to the original code. That effectively shifts the cash-flow burden to the practice, and a time sink for the staff.State societies are already warning that this will delay payment and raise admin costs.
It’s not just “a few bad actors.” Even Cigna’s “less than 3%” talking point still means edits will hit plenty of legitimate claims, because they plan to apply the screen to everyone. In 2025, when margins are tight, every dollar matters.
It hits specialties we actually serve. Early pushback includes rheumatology and podiatry, both heavy on chronic, complex care where high-level E/M visits are common. Rheum, GI, neuro, cardiology, complex primary care? Expect disruption.
What can your practice do right now
- Audit Cigna remits daily. Flag any 99214/99215 or 99204/99205 payment that comes back one level lower than billed. Build a weekly report.
- Make the note bulletproof. If you leveled by time, write the total time and qualifying activities clearly. If you leveled by MDM, make the problems, data, and risk obvious in the first five lines.
- Have an appeal kit ready. Cover sheet, claim line, original code rationale, visit note. Keep templates for Time and MDM so staff can swap in the specifics. Cigna’s own page explains that you must send the full record to reverse the downcode.
- Escalate with your society. CMA, TMA, AMA and others are already on record. Add your data so the story is volume plus impact, not anecdotes.
Thrivory’s take, and how we can help
This is the kind of “accuracy” that quietly shaves payments and slows cash flow. That combination hurts access and growth — and it’s exactly where Thrivory can lean in.
- Proactive monitoring, not just cleanup. Because we integrate with PMS systems and watch claim flows, we can track your Cigna E/M lines for 99204-99205, 99214-99215, 99244-99245, and alert you the moment a payment comes in one level lower than billed. Think of it as an R49 Watchlist with weekly dashboards and a live feed into your billing queue.
- Pre-submission “R49 risk” hints. Using our claims intelligence, we can flag combinations Cigna is likely to question and nudge your team before the claim goes out (“Time not explicit – add total minutes” or “MDM risk unclear – cite management risk or data review”).
- Specialty heatmaps. We’ll monitor and publish periodically a running view of downcoding rates by specialty and state, and spotlight high-risk segments that overlap with our core base (rheum and GI infusion practices included.)
- Cash-flow buffer while you fight. If you’re hit with a wave of downcodes, we can still advance on those encounters and settle when the appeal pays. The policy creates delays by definition; our design neutralizes delay.
You shouldn’t have to be your own claims detective. Thrivory turns this into a solvable problem.
Final Thoughts
At the end of the day, I believe Cigna is actually trying to make it easier to get paid. It remains to be seen whether this policy will achieve that. Still, it’s hard not to meet the stated goal of “reducing administrative burden” with a bit of cynicism, especially when they hand us a fax number.
Practices shouldn’t have to jump through hoops to be paid correctly for complex care.
We’ll keep working with clients to monitor the impact and adapt.