The planned policies from Aetna and Cigna represented a significant shift in how payers handle high-level office visits. The following table summarizes the core elements of these policies based on available information.
| Policy Aspect | Cigna’s R49 Policy (Currently Paused) | Aetna’s Claim & Code Review Program (CCRP) |
|---|---|---|
| Effective Date | Officially paused as of Oct. 1, 2025 | Reportedly active since March 2025, expanded Sept. 2025 |
| Targeted Codes | 99204-99205, 99214-99215, 99244-99245 (Level 4 & 5 E/M codes) | Level 4 and 5 E/M codes (e.g., 99214, 99215) |
| The Mechanism | Automatic downcoding by one level based on claims data (e.g., diagnosis codes) without initial medical record review. | Pre-payment downcoding by vendor coders reviewing coding data, not the full clinical chart. |
| Appeal Process | Required providers to submit appeals and medical records via fax. | Requires providers to identify the underpayment and appeal to receive the full contracted rate. |
How to Protect Your Practice: A Defensive Action Plan
Despite the pause on Cigna’s policy, the underlying trend of automated downcoding means strengthening your internal processes is a crucial defensive measure.
Audit and Educate: Proactively review your E/M documentation and coding for levels 4 and 5. Ensure your providers and coders are thoroughly trained on current AMA E/M guidelines, which emphasize Medical Decision Making (MDM) or time as the basis for code level selection—not the history and exam elements from older rules that your email mentions.
Document to Justify Medical Decision Making (MDM): Since MDM is the cornerstone of coding, your documentation must clearly reflect the complexity of the patient’s problems, the amount and complexity of data reviewed, and the risk of patient management complications.
Leverage Time-Based Coding: As your email suggests, time can be a defensible pathway. Document the total time spent and the specific activities performed (e.g., care coordination, patient education) to justify codes like 99215 (40 minutes) if time is the basis for the code level.
Monitor Payments Closely: Scrutinize Explanation of Payment (EOP) documents from all payers. Aetna’s downcoding, for instance, may not come with a denial notice, so you must compare the billed code against the paid code to spot discrepancies.
Understand the “Bypass” and Appeal Processes: Your analysis of Cigna’s bypass option as “guilty until proven innocent” is astute. According to Cigna’s policy, providers can request a bypass after five adjusted claims by submitting records for review; if 80% were billed correctly, the bypass is granted. This is a rigorous process that requires flawless documentation.
The Bigger Picture: Advocacy and Impact
Major medical associations have been actively challenging these policies, which they argue increase administrative burdens, undermine clinical judgment, and threaten the financial viability of practices, especially independent ones. The California Medical Association’s (CMA) inquiry, for example, directly led to Cigna pausing its policy for review by state regulators.
