Dear Provider,
HNS has recently been made aware that, effective October 1, 2025, Cigna will implement a new E/M reimbursement policy for E/M codes 99204-05 and 99214-15. This new policy seeks to ensure that these higher-level E/M codes are being properly billed in accordance with coding manual guidelines.
In pertinent part, for dates of service on or after 10/1/2025, Cigna may adjust E/M codes 99204-05 and 99214-15 to a single level lower when encounter criteria on a claim does not tend to support the higher-level E/M CPT code reported. For example, a claim may be adjusted as follows: 99215 to 99214, or 99214 to 99213.
Claim encounter criteria includes all data that can be reported on a CMS 1500 form, e.g. patient sex, patient DOB, date of current illness/injury, diagnosis codes, diagnosis pointers, procedure codes, units billed, etc.
Two Important Notes:
- As you know, you should always report the most appropriate level of E/M code to HNS contracted payors, and your documentation must clearly support the level of E/M service billed.
- If you have an E/M service downcoded as a result of this policy, and your medical documentation supports reimbursement for the originally submitted code, you may request reconsideration by submitting the request, along with the patient’s full record for the applicable DOS, to the secure Cigna fax number (833) 392-2092.
For more detailed information about the policy, you may review it by clicking the following link:
Cigna Evaluation and Management Coding Accuracy (R49) (eff. 10/1/25).
To learn more about requirements for billing different levels of E/M services, we encourage you to review the HNS “2021 E/M Code Changes” CE program on the secure portal of the HNS Website.
As we learn additional pertinent information about this new policy, we will share it with the HNS Network.
Sincerely,
HNS