How the FMA is monitoring Cigna’s downcoding initiative

By Jarrod Fowler, MHA, FMA Director of Health Care Policy and Innovation

 

Cigna has introduced a new reimbursement policy titled “Evaluation & Management Coding and Accuracy (R49)”, which becomes effective for dates of service on or after Oct. 1, 2025.

  • Under the policy, Cigna reserves the right to automatically downcode a claim — reduce reimbursement by one E&M level (e.g., 99215-99214) — if “the encounter criteria on the claim does not support the higher‐level E&M CPT code reported.”
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  • The policy applies to in‑network providers nationwide, and according to Cigna, only a small percentage (~1%) of providers will be affected. Specifically, the policy is designed to target practices with higher rates of Level 4/5 E&M codes relative to peers and whose documentation or diagnosis coding may not support that level.
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  • Cigna is presenting this initiative as a coding‑accuracy program to align with nationally recognized guidelines and to address potential over‑coding. Understandably, many physicians are skeptical that the initiative will not affect appropriately coded claims.

 

More information from Cigna is available here. 

 

What the FMA is doing

Cigna representatives met with the FMA and informed us that very few physicians will be affected, and that the initial press release led many physicians to erroneously believe they would be affected when, in reality, the vast majority of practices will never be subject to the policy. Cigna described this as a miscommunication on the company’s part.

However, the FMA is interested in monitoring the situation to determine if additional advocacy is needed. We strongly oppose all inappropriate downcoding initiatives.

 

Get in touch with us

If you are receiving downcoding adjustments from Cigna and believe they are inappropriate, please notify the FMA by emailing jfowler@flmedical.org. FMA members affected by other downcoding initiatives are also encouraged to contact us. This information will help our advocacy team assess the impact of Cigna’s initiative and evaluate the need for additional action. We will also provide direct assistance to affected members whenever possible.