Cigna Reimbursement Policy – Effective October 1, 2025

Cigna Healthcare has introduced a new reimbursement policy for evaluation and management (E/M) claims, focusing on coding accuracy and industry standards.

Key Highlights

Effective Date: October 1, 2025
Applies To: CPT® E/M codes 99204-99205, 99214-99215, and 99244-99245

What’s New

• New Policy: “Cigna Healthcare Evaluation and Management Coding Accuracy (R49)” aligns with American Medical Association (AMA) coding guidelines.

• Provider Impact:

  • Only providers who consistently bill higher E/M levels for routine services, compared to their peers, are affected.

  • About 99% of in-network providers are not impacted, including 97% who bill level 4 and 5 E/M codes.

How Claims Are Evaluated

• Applies to level 4 and 5 E/M claims from affected providers when submitted documentation does not justify the level billed.

• If claims are adjusted, Cigna issues prompt payment for lower-level codes and notes adjustments on the Explanation of Payment (EOP).

Reconsideration & Appeals Process

• Providers may submit the full patient encounter record for reconsideration:

  • Submission via secure fax: 833.392.2092

  • If the records support the original code, Cigna will reimburse at the original level.

  • If denied, providers can pursue an administrative appeal.

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Need Support?

Consulmed specializes in Revenue Cycle Management for healthcare providers, physician groups, and rural practices. Our services include:

• Accurate billing & coding

• Fast claim resolution

• Expert denial management

• Custom technology solutions

Contact Consulmed:

• Phone: 801-296-2113

• Toll Free: 800-399-6438

• Email: info@consulmed.com

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