An increasing number of payers are automatically ‘downcoding’ claims, resulting in lower payment, and the practice is gaining national attention. An Oct. 9 NBC News story took a look at the problem. While physician practices may be allowed to appeal a claim that has been automatically downcoded, it assumes the practice even catches the change.
Effective Oct. 1, 2025, Cigna has implemented a new reimbursement policy for evaluation and management (E&M) claims. This policy will review certain professional claims billed with CPT E/M codes 99204-99205, 99214-99215, and 99244-99245 for billing and coding accuracy. Under the policy, Cigna will automatically downcode services for providers the company says have a "consistent pattern of coding at a higher E&M level for routine services compared to their peers.” Providers who have services downcoded will have the opportunity to appeal those claims. Concerns with the policy include added administrative burden on providers to appeal claims that have been wrongly downcoded, and the lack of transparency and use of automation in the downcoding process.
ACOI encourages its members to be vigilant in reviewing claims and encourages reporting of problems to ACOI at tmcnichol@acoi.org.