The planned policies from Aetna and Cigna represented a significant shift from, “if it wasn’t documented it wasn’t done” to “guilty until proven innocent” – with payers automatically denying level four and five office visit codes with no review of medical record documentation. The following table summarizes the core elements of these policies based on available information.
| Cigna’s R49 Policy | Aetna’s Claim & Code Review Program (CCRP) | |
|---|---|---|
| Effective Date | Originally planned for October 1, 2025. Advocacy organizations report that implementation has been delayed, but the policy is still on the Cigna website with an effective date of October 1, 2025. | Reportedly active since March 2025, expanded September 2025. |
| Targeted Codes | 99204–99205, 99214–99215 (Level 4 & 5 Office Visit Codes) | |
| The Mechanism | Automatic downcoding by one level based on claims data (e.g., diagnosis codes) without initial medical record review. | Pre-payment downcoding by contracted coders reviewing coding data, not the full clinical chart. |
| Appeal Process | Requires providers to submit appeals and medical records via fax (seriously?!) | Requires providers to identify the underpayment and appeal to receive the full contracted rate. |
How to Protect Your Practice: An Action Plan
The underlying trend of automated downcoding means that strengthening your offensive and defensive tactics is critical to avoid a sudden unexpected drop in revenue.
→ Cigna’s Bypass Option: Cigna has developed an option to bypass the automated downcoding for practices willing to submit to a voluntary chart audit. By submitting the medical records for a set of automatically downcoded claims. If Cigna determines that 80% were billed correctly based on auditing the charts, the bypass is granted. This option is risky because the recourse is not clear whether there are appeal options if this audit is unfavorable. This approach deems the “guilty until proven innocent” of upcoding office visits. Practices taking this approach should carefully choose the records for submission. Annotating the records with the elements supporting the originally submitted codes is recommended to clearly communicate the support for the level submitted.
→ Audit and Educate: Proactively review your E/M documentation and coding
or levels 4 and 5. Ensure your providers and coders are thoroughly trained on current AMA E/M guidelines, which are based on Medical Decision Making (MDM) or time as the basis for code level s election.
→ Document to Justify MDM: MDM is the driver for the vast majority of office coding and your documentation must clearly reflect the complexity of the problems addressed , the amount and complexity of data reviewed, and the risk of patient management complications.
→ Time-Based Coding: When coding office visits based on time, document the total time spent on the date of service and the qualifying activities performed (e.g., care coordination, patient education) to justify code assignment. If there are other codes on the claim, clearly document that the total time documented is exclusive of time spent on other services.
→ Monitor Payments Closely: Scrutinize remittance advice documents and analyze data from all payers to ensure that the amount allowed by the payer matches the contracted rate. Some of this downcoding may be a change in the payment rate, with no notice of denial or change in coding, so you must compare the expected rate against the allowed amount to spot discrepancies. Overall, this is a good practice for your top revenue producing codes to detect and correct underpayments from insurance companies. It takes some time to load all of the contracted rates into the practice management system and match the rates to the correct payer, but data analysis is a key strategy to catch underpayments and pursue corrections.
The Bigger Picture: Advocacy and Impact
Major advocacy organizations have been actively challenging these policies, which they argue increase administrative burden, undermine clinical judgment, and threaten the financial viability of medical practices. The American Medical Association (AMA), California Medical Association (CMA), and American Academy of Family Physicians (AAFP) opposed the policy and have reported that Cigna agreed to delay implementation.
Physicians and medical groups may to contact Cigna directly to object to the policy. Call Cigna Customer Service at (800) 88-Cigna (882-4462) or through the provider portal to share concerns and request that the insurer permanently withdraw the R49 downcoding policy. When communicating with Cigna, it is recommended that practices emphasize that the policy:
- Conflicts with AMA and CMS E/M guidelines.
- Lacks transparency regarding claims adjudication criteria.
- Increases administrative costs for both providers and the payer.
- Undermines accurate reimbursement for complex patient encounters.
To learn more about Aetna’s Evaluation and Management (E&M) Program Claim and Code Review, click this link to read the PDF →
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