The Pulse by Peregrine
February 2026 Revenue & Compliance Update
You’ve Earned the Revenue. Let’s Make Sure You Keep It.
Featured Insight:
Level 4 & 5 E/M Visits Under Scrutiny
Beginning October 1, 2025, Cigna and Aetna implemented new E/M reimbursement policies targeting Level 4 and Level 5 visits.
If documentation does not fully support reported complexity or time, visits may be downcoded.
We are actively seeing this occur.
Codes impacted: 99204, 99205, 99214, 99215, 99244, 99245
Cigna (Policy R49)
- Automatic one-level reduction when criteria are not met (e.g., 99215 → 99214)
- Reconsideration available if records support the original level
Aetna Claim & Code Review Program
- Applies across multiple care settings
- Reviews conducted by certified coders using CMS and AMA E/M guidelines
- Claims may be revised downward; appeals require medical record submission
The message is clear: Level 4 & Level 5 documentation must withstand structured payer review.
Featured Download: E/M MDM Quick Reference Grid
We are sharing the CPT Revised MDM Grid for Office Visits (99202–99215) to support accurate Level 4 and Level 5 billing.
This one-page tool outlines:
Moderate (99214) vs. High (99215) requirements
Required data combinations
Risk thresholds
Documentation alignment standards
Reminder: CMS eliminated the 1995/1997 guidelines. Levels are now determined by:
- Medical Decision Making (2 of 3: Problems, Data, Risk)
- OR
- Total Time on the date of service
If documentation does not clearly support MDM, payers will default downward.
Medicare Telehealth Extended Through 2027
Congress has extended key Medicare telehealth flexibilities through 2027.
This provides:
Continued reimbursement stability No coverage gap Ongoing geographic flexibility Coverage continuity for eligible services
However, telehealth claims remain subject to documentation and modifier scrutiny.
We recommend confirming:
- POS accuracy
- Modifier selection
- Time documentation alignment
- MDM support when billed by complexity
Read our full Telehealth Extension Update and CMS FAQ summary here
HIPAA & Substance Use Disorder Policy Update Required
As of February 16, 2026, covered entities must have updated their Notice of Privacy Practices (NPP) to align with federal Substance Use Disorder confidentiality requirements.
If your NPP has not been revised, your practice may be out of compliance.
Updates include:
Revised consent language Expanded redisclosure restrictions Alignment between HIPAA and 42 CFR Part 2 Updated patient rights language
We strongly recommend confirming updated NPP language is implemented across all practice locations.
Peregrine Resource Center
Peregrine Healthcare tracks payer, Medicare, and compliance changes so your practice stays informed without inbox overload.
Each month, we summarize what changed since the prior issue so your team can focus on patients, not policy hunting.
For official source updates, we recommend subscribing directly to:
Centers for Medicare & Medicaid Services
American Academy of Professional Coders
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Peregrine Breakroom Quick Self Check
Peregrine Breakroom Quick Self CheckDo you know your practice’s:
- % of Level 4 vs Level 3 visits?
- % of Level 5 visits?
- Average reimbursement per E/M visit by payer?
- Downcoding rate by Cigna or Aetna?
- Denial rate tied specifically to E/M?
- Telehealth modifier accuracy rate?
If not, that is your first opportunity.
Explore more insights: peregrinehealthcare.com/