Cigna generally pays claims as providers bill them unless there is an audit or explicit request for additional documentation that results in downcoding, denial, or adjustment. However, starting October 1, 2025, that process will change for some providers when they bill levels 4 and 5 evaluation and management (E/M) office visit codes. 

It’s all thanks to a Cigna R49 payment policy change allowing the payer to automatically downcode higher-level E/M office visit codes by 1 level if the information submitted does not clearly support the complexity of the E/M code billed. 

Here's a quick overview of important facts about the Cigna R49 payment policy change:

Read on for more details about this change and how it may affect your practice or billing company.

The good news is that Cigna says almost 99% of all in-network providers will not be affected by the Cigna R49 payment policy change. 

At-risk providers are those who:

Pre-emptively downcoding claims is not the answer. Instead, providers must focus on clinical documentation improvement to support billed services.

They can — and should — also request Cigna to reconsider individual claims. Cigna says certified coders will evaluate all claims submitted for reconsideration to ensure a thorough coding review prior to a final determination. 

Also, once providers have experienced at least 5 adjusted claims under the Cigna R49 payment policy change — and 80% or more of their claims are deemed correct upon review — they can apply for a policy bypass, exempting them from repeated downcoding of E/M office visit codes.

According to Dr. Soma Mandal, MD, “While the intent of this policy is to improve coding accuracy, pre-emptive downcoding risks unfairly penalizing providers who deliver complex care. Strong documentation and proactive workflows will be essential to ensure patients continue to receive the level of care they need without disruption.”

If you think you may be at risk for downcoding under the Cigna R49 payment policy change, here are 5 steps you can take now to prepare.

Review time-based coding and MDM criteria for E/M office visit codes in AMA’s 2021 E/M guidelines. 

When billing E/M office visit codes based on MDM, ensure each note clearly shows the number and complexity of problems addressed, amount/complexity of data reviewed and analyzed, and risk of morbidity/mortality. 

When billing E/M office visit codes based on time, ensure the note clearly shows the exact time spent on the encounter.

Consider human review of any level 4 or 5 E/M office visit codes prior to submission to ensure documentation reflects clinical complexity and/or time spent.

Identify staff who can monitor payment trends and push back quickly against inappropriate downcoding under the Cigna R49 payment policy change using pre-built appeal letters.

Practices with limited revenue cycle management support or coding compliance staff may want to consider partnering with an outsource vendor to ensure compliance and revenue integrity.

Track the number of claims that Cigna downcodes under the Cigna R49 payment policy change, the number your practice resubmits, and the number of claims ultimately paid at the higher (original) E/M level. 

If this policy for E/M office visit codes is successful for Cigna, other payers may follow suit with downcoding. That’s why it’s so important to know where you stand, identify your vulnerabilities, and take proactive steps to improve compliance.

To learn more about Cigna’s new E/M policy for E/M office visit codes, view its Frequently Asked Questions. 

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