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NEW POLICIES • 2025

Cigna R49 & Aetna CCRP: E/M Downcoding Policies 2025

Cigna’s new R49 policy (effective Oct 1, 2025) and Aetna’s expanded Claim & Code Review Program (effective Sep 1, 2025) both allow insurers to automatically downcode Evaluation & Management (E/M) visits when documentation does not fully support higher-level codes such as CPT codes 99204, 99205, 99214, 99215, 99244, and 99245.This “deny-first, pay-later” approach poses risks to physician revenue, administrative burden, and potentially patient access. Providers must document thoroughly, monitor remittances, and appeal aggressively to protect reimbursement.

What Is E/M Downcoding?

Definition:

E/M downcoding is the process by which insurance payers adjust (reduce) the reimbursement for high-level visits if proper documentation is lacking.Downcoding occurs when a payer changes a claim submitted at a higher E/M level (e.g. 99214, 99215) to a lower-level code (e.g. 99213), thereby paying less than what the provider billed.

Definition:

Modern downcoding is often driven by claim-editing software algorithms, sometimes with minimal or no clinical review of documentation. (American Medical Association)

Differing from denials:

Unlike a denial, which refuses payment, downcoding pays—but at a lower level. Many practices may not spot the adjustment unless they carefully review remittance advice and EOBs.

Why insurers do it : 

As payers look for cost savings, downcoding allows them to reduce payments in aggregate, especially under large volumes of claims. (asipp.org)

Which CPT Codes Are Affected by the Downcoding Policy?

Cigna and Aetna target these CPT codes for downcoding, effective October 1 and September 1, 2025:

99204, 99205

New patient, moderate/high complexity

99214, 99215

Established patient, moderate/high complexity

99244, 99245

Consultation, moderate/high complexity

Cigna’s R49 Reimbursement Policy (Effective Oct 1, 2025)

🔹  Cigna R49 policy 2025 applies to CPT® codes: 99204–99205, 99214–99215, 99244–99245

🔹  Policy: Cigna may adjust down by one level  if the claim documentation doesn’t support the higher-level code.

Example: 99215 → 99214, 99214 → 99213

🔹  Documentation requirements: Must align with AMA E/M guidelines (medical decision making or time).

🔹  Provider recourse: If supporting medical records are submitted and complexity/time is validated, Cigna will reimburse at the originally submitted level.

📌 Impact

Downcoding a single high-level claim reduces reimbursement by $40–$60 per visit — adding up to thousands annually for busy practices. Try mirro.ai’s Undercoding Recovery Estimator.

While Cigna asserts that its policy is consistent with the American Medical Association’s CPT coding guidelines, its use of claim-level criteria to determine the appropriateness of E/M levels, without considering the documented total time or medical decision-making, appears inconsistent with both AMA and CMS guidelines,”

– the California Medical Association said (Becker’s Healthcare)

The Texas Medical Association (TMA) also reported that the R49 policy does not apply universally. Cigna confirmed that individual physicians may request removal from the review process after appealing five downcoded claims. If those appeals show that at least 80% were billed appropriately, the physician can bypass future downcoding reviews. Notably, this exemption applies at the individual physician level, not the group level (TMA).

“Providers meeting the 80% threshold after 5 appeals may request exemption from ongoing downcoding reviews (applies at the individual physician level, not group).”

Aetna’s Claim & Code Review Program (CCRP)

Aetna is tightening its scrutiny of high-level E/M services.

What Aetna Has Published

🔹  The expanded Aetna CCRP downcoding 2025 (e.g., the NY policy) specifically targets Level 4 and 5 E/M visits (99214–99215, 99204–99205). 

🔹  Claims may be reviewed and adjusted if documentation does not meet AMA/CMS standards.

🔹  Updates in OfficeLink newsletters (March 2023, June 2025) confirm that CCRP is expanding effective September 1, 2025, to include broader claim edits.

Why These Policies Matter

  • Revenue Risk

    Routine downcoding erodes practice margins, especially in small or independent clinics.

  • Compliance Pressure

    Both CMS and OIG have identified E/M as one of the most error-prone categories of coding. These policies signal that commercial payers are aligning with federal audit trends.

  • Operational and Documentation Burden

    Providers must ensure meticulous documentation of MDM and time to prevent unjustified downgrades.Practices must dedicate staff to reviewing EOBs, appealing claims, and updating documentation processes.

Impact on Medical Practices

Providers may face:

  • Reduced reimbursement for high-complexity visits.

  • Increased administrative cost and paperwork for appeals.

  • Greater scrutiny of coding patterns.

  • The need to update coding and documentation workflows.

When reimbursement is reduced, physicians may shift toward higher volume, lower-risk patients or consolidate into larger systems, risking access and continuity of care.

How Providers Can Respond

  • Leverage AI documentation tools (like mirro.ai):

    Ambient and real-time AI can listen to encounters and document thoroughly, ensuring complexity, MDM, and time are fully captured. This reduces undercoding and protects against payer downcoding.

  • Strengthen documentation practices:

    Even with AI, providers must confirm that notes clearly reflect MDM, time spent, and clinical decision making in alignment with AMA E/M guidelines.

  • Audit remittances:

    Downcoding adjustments often fly under the radar. Practices must review EOBs regularly to catch when payers reduce reimbursement.

  • Appeal consistently:

    Submit full encounter records when higher-level coding is justified. Frequent appeals improve chances of recovering revenue and, in Aetna’s case, may lead to removal from ongoing monitoring.

  • Use precise ICD-10 codes & link diagnoses to MDM:

    Avoid unspecified codes and ensure coding reflects the documented complexity.

  • Train clinicians on updated E/M guidelines (2021/2023/2024):

    Reinforce correct coding logic and how documentation supports billing at the appropriate level.

Cigna’s R49 policy and Aetna’s CCRP expansion mark a new era of payer-driven downcoding. It’s a shift that favors payer cost control over transparency, provider autonomy, and fair payment. For providers, the takeaway is clear: documentation is now under a microscope. Practices must invest in better note-taking(eg: mirro.ai), proactive auditing, and consistent appeals to avoid revenue leakage.

By staying vigilant — and embracing smarter documentation tools — providers can safeguard compliance and protect the revenue they rightfully earn.

References

  1. Cigna Healthcare. Reimbursement Policy R49: Evaluation and Management Coding Accuracy.  (Link)
  2. Cigna Healthcare. R49 Evaluation and Management Coding Accuracy. Internal policy update; July 1, 2025.
  3. Aetna. NY E/M Code & Claim Review Program. Accessed September 30, 2025. https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/ny-em-code-claim-review.pdf
  4. Aetna. OfficeLink Updates – March 2023: Claim & Code Review Program Update. Accessed September 30, 2025. https://www.aetna.com/health-care-professionals/newsletters-news/office-link-updates-march-2023/90-day-notices-march-2023/claim-code-review-program-update.html
  5. Aetna. OfficeLink Updates – June 2025. Accessed September 30, 2025.  https://www.aetna.com/health-care-professionals/newsletters-news/office-link-updates-june-2025.html
  6. Aetna. OfficeLink Updates – April 2025. Accessed September 30, 2025. https://www.aetna.com/content/dam/aetna/pdfs/olu/officelink-updates-april-2025-olu.pdf
  7. American Podiatric Medical Association. APMA Takes Action: Engaging Aetna on Downcoding Policy. Published 2025. Accessed September 30, 2025. https://www.apma.org/about-apma/news/news-releases/2025/apma-takes-action-engaging-aetna-on-downcoding-policy/
  8. Davis Wright Tremaine LLP. Aetna Expanded Claim Edits Effective September 2025. Published June 2025. Accessed September 30, 2025. https://www.dwt.com/insights/2025/06/aetna-expanded-claim-edits-september-2025
  9. Indiana State Medical Association. Aetna Expands Claim & Code Review Program. Published June 12, 2025. Accessed September 30, 2025. https://www.ismanet.org/ISMA/Resources/e-Reports/6-12-25/Aetna.aspx
  10. The Rheumatologist. Aetna Expands Evaluation & Management Downcoding Program. Published 2025. Accessed September 30, 2025. https://www.the-rheumatologist.org/article/aetna-expands-evaluation-management-downcoding-program/
  11. Becker’s Healthcare. Medical Associations Push Back on Cigna’s New Downcoding Policy. Published 2025. Accessed September 30, 2025. https://www.beckerspayer.com/policy-updates/medical-associations-push-back-on-cignas-new-downcoding-policy/
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