Beginning October 1, 2025, both Cigna and Aetna are launching new Evaluation & Management (E/M) reimbursement policies that could directly reduce payment for higher-level visits. These changes focus on downcoding Level 4 and 5 E/M services if the submitted documentation doesn’t fully support the reported complexity or time.

For physicians and practice managers, that means more scrutiny, more administrative burden, and a greater need for airtight documentation.

Cigna E/M Reimbursement Changes (Effective Oct 1, 2025)

Under its new Evaluation and Management Coding Accuracy Policy (R49), Cigna may automatically downcode Level 4 and 5 visits:

• Codes Impacted: 99204, 99205, 99214, 99215, 99244, 99245
• Adjustment Process: If documentation doesn’t meet criteria, Cigna will reduce the service by one level (e.g., 99215 → 99214, or 99214 → 99213).
• Provider Option: If medical records are later submitted that confirm the higher-level service (via Medical Decision Making (MDM) or time), Cigna will reimburse at the original level.

📄 Read the full Cigna policy (PDF)

Aetna E/M Code Review Program Explained

Aetna’s Claim and Code Review Program also targets Level 4 and 5 E/M visits across multiple care settings.

• Scope: Applies to new and established patient visits, outpatient hospital, urgent care, consultations, and ophthalmology.
• Review Process:
• Conducted by certified coders (not clinicians)
• Compared against CMS and AMA E/M guidelines
• Focuses on history, physical exam, MDM, time, counseling, and problem complexity
• Outcome: Claims deemed unsupported may be revised downward.
• Appeal Rights: Providers can appeal by submitting medical records through the EOB address or Availity provider portal.

📄 Read the full Aetna program overview (PDF)

How to Avoid Downcoding Through Documentation

To reduce your risk of Cigna and Aetna E/M downcoding, providers should:

1. Document MDM in detail: Include complexity of problems, data reviewed, and risk of management decisions.
2. Use time correctly: Total time must reflect face-to-face and non-face-to-face care on the date of service.
3. Match documentation to CPT® requirements: More notes don’t equal higher levels; quality and alignment matter most.
4. Prepare for appeals: Be ready to submit records when claims are downcoded.

How Peregrine Healthcare Protects Your E/M Revenue

At Peregrine, we know payer downcoding tactics increase administrative work and put practice revenue at risk. Here’s how we safeguard your reimbursement:

• Payment Monitoring: Every claim is checked against standard allowables.
• Flag & Review System: Downcoded or underpaid claims are immediately flagged by our A/R team.
• Reprocessing & Appeals: We contact payers for reprocessing and escalate with appeals when needed.
• Provider Education: We guide physicians and staff on the E/M documentation standards that withstand payer scrutiny.

Key Takeaways

• Cigna and Aetna will both begin downcoding Level 4 & 5 visits starting Oct 1, 2025.
• Claims may be reduced or delayed unless documentation fully supports the billed level.
• Providers should focus on precise MDM and time documentation.
• Peregrine Healthcare provides proactive monitoring, appeals, and documentation support to protect your practice’s revenue.

Next Step for Your Practice
Don’t let downcoding and delays drain your revenue.
👉🏽Schedule your Complimentary Review and strategy session with Peregrine Healthcare today.
📲 Call 877-463-1110