What’s happening: Cigna’s “E/M Coding and Accuracy” policy () would allow automatic one-level downcoding of 99204–99205, 99214–99215, and 99244–99245 when Cigna deems “encounter criteria” unmet.
Why it matters for GI: GI visits often involve complex medical decision making or total time that justifies higher levels. Diagnosis codes or claim proxies alone cannot determine E/M level under CPT; automatic downcoding risks inappropriate underpayment and added appeals burden.
¶¶Òô´ó¹Ï’s position: ¶¶Òô´ó¹Ï sent a letter opposing this policy. At minimum, Cigna should pause implementation, disclose process for algorithmic downcoding, require clinician-led medical record review before any level change, publish a transparent, specialty-appropriate methodology (thresholds, comparators, CPT citations), provide rapid electronic appeals with no retroactive recoupments, and report adjustment/reversal rates.
To date, Cigna has not shared the triggers, thresholds, or remittance rationales for downcoding—lack of transparency that undermines due process, increases administrative burden, and impedes physicians from contesting improper reductions.
What practices should do now:
- Document E/M by MDM or total time; make problems, data, and risk explicit.
- Update templates and train teams on 2021+ E/M rules.
- Set an appeals workflow and track any downcodes.
Tell us if you’re impacted: Share examples of downcoding and outcomes with ¶¶Òô´ó¹Ï (omit unnecessary PHI). We’ll keep members updated and provide tools to protect appropriate payment for complex GI care.