If you haven’t heard, or have heard but still can’t get your head around it, let’s walk through what was recently announced by Cigna.

Cigna released a new policy set to take effect on October 1, 2025, which will automatically downcode CPTs 99204, 99205, 99214,99215, 99244, and 99245 to a lower level at the point of adjudication. This has raised a massive amount of public scrutiny in addition to begging the question, why would they do that before requesting records? In addition, why would they do that to providers with no known coding or documentation issues?

These are all great questions but there hasn’t been a lot of insight circulating. What has been heavily making the rounds are the big names opposing the policy including associations like the American Academy of Family Physicians, The American College of Rheumatology. State medical associations including California’s and Texas’. Even the American Medical Association jumped in to create a user guide for medical providers on how to navigate “Payer Evaluation and Management (E/M) Downcoding Programs”.

So, How Did We Get Here?

Unfortunately, down-coding by payers is not new. This is a tactic they’ve used for many years for a multitude of reasons. First and foremost, it’s partially exactly what you’re thinking. Yes, they want to reduce their own expenses, as do we all, and some payers (not all) are doing it just because they know you don’t have time to appeal the claim.

That said, there are also other factors that drove this industry shift, we don’t want the payers to lump all of our provider clinics in with the bad actors committing fraud or doing harm. So, we can’t do that either. We just can’t assume all payers are bad, no matter how many great jokes I have about them all.

So, let’s genuinely consider their decisions because we will never solve the issue without talking about the root cause.

Problem #1: Inadequate documentation.

There has been a long history, particularly post-shift from paper to electronic charting, of insufficient provider documentation. We know the reasons for lacking documentation:

  • Inconsistent structures for learning this in medical school

  • Difficult electronic systems with complex configurations

  • Lack of time to even go to the bathroom let alone chart

  • Reimbursement so low you have to see patients every fifteen minutes and through lunch, saving charting for while your kid is in the tub just so you can make payroll

Yes, we are aware that many of our providers need support to really hone their documentation skills and providers know that too. In fact, to compensate for what they believe may not be adequate documentation, providers frequently downcode their own services before the bill ever goes out the door.

They often pick a level 2 or 3 for a high complexity visit that should’ve been a level 4 or 5, trust me, I’ve asked them. This takes us directly into the next issue.

Problem #2: Potentially inaccurate bell-curve data. The bell-curve for E/M visits is a long-standing metric of evaluating provider coding by comparing the utilization of individual providers or groups against the utilization of their peers at the national level. This data is populated into a chart that creates a “bell-curve” out of the data. Providers who do not align with the bell curve, may be flagged for auditing, pre-payment review, or… automatic downcoding.

Why? Because statistically they appear to be an outlier. If we dig past that though, we see the bigger picture. Why does it appear to be an outlier? That’s an easy one…

Decades of providers downcoding themselves has created a dataset that is irreparably skewed, and documentation is still a challenge. So, the bell-curve data is accurate in that, it reflects what was billed. But does it accurately reflect the level of complexity and services provided in the exam rooms?

Problem #3: This isn’t new.

  • In 2019, UHC changed their policies from automatic denials (when documentation didn’t support E/M levels, to granting downcode authority to themselves. The policy was aimed specifically at level 4 and 5 visits and would require an appeal to overturn. Sounds familiar only they were at least requesting records first.

  • In 2022, UnitedHealthcare was sued over downcoding and TeamHealth was awarded $60 Million in punitive damages.

  • In 2023, Virginia’s College of Emergency Physicians won a federal lawsuit against the Virginia Department of Medical Assistance Services because of their downcoding policies.

  • In 2023, Cigna was questioned by a Congressional Committee for allegedly using an AI-based tool to deny claims and authorizations without reading the chart notes.  In 2003, Cigna settled a case with 700,000 providers related to computer-based downcoding.

  • In 2024, Aetna issued a policy directed at emergency providers to similarly downcode level 4 and 5 visits but the pushback in California saw them rescind the policy shortly after issuance.

Now What? Well, we could keep the list of problems going and discuss them long into the evening but let’s face it, you probably still have charting to do. That leaves us with where we stand now:

  • We have payers who are, and have been, automatically downcoding based on what they believe is sound and long-standing statistical information (sure, some may be just doing it for the heck of it, but that’s rarer than you’d think)

  • We have providers with a paper-thin margin who are now forced to increase their administrative burden to appeal these claims just to get the money they were due to receive. O, and private practices and rural hospitals get the extra pain of not having the economies of scale present at hospital systems to implement that oversight, auditing, and appeal strategies.

There are numerous reasons that the healthcare industry can’t make operational advances like every other industry but largely because in any other industry a bill invoiced would simply be paid.

In an ideal world, payers would work in collaboration to help provide education to providers on documentation, they would work in concert with providers to periodically audit and to downcode after reviewing records and only when the documentation did not support the service rendered, and they would find other ways to isolate any bad actors in the community instead of applying a generalized punishment to the industry.

We are overdue in repairing these broken provider-payer relationships, if you’re interested in being part of positive, forward thinking discussions, led with mutual understanding and respect then shoot me a message, we have to start the conversation somewhere.

If you just want to know how to identify down-coded claims and get them appealed, let me know, I’m to happy to help develop a strategy that is achievable.