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Effective October 1, 2025, Cigna will implement a new policy that may result in the downcoding of Evaluation and Management (E/M) services , with a particular focus on Level 4 and Level 5 office visits. This aligns with similar initiatives already in place by other major commercial payers. Below is a summary of the key policies from Cigna, Aetna and BlueCross BlueShield of Tennessee.

Cigna

Cigna’s Evaluation and Management Coding Accuracy medical reimbursemen policy begins October 1, 2025, and applies to codes 99204-99205 and 99214-99215. According to Cigna, the policy is expected to have a limited impact and will only apply when billing is insufficient to support the reported level of service. It targets providers who consistently code at higher levels compared to their peers. Providers may request reconsideration by submitting complete encounter documentation.

Aetna

Aetna’s Claim and Code Review Program is already in effect. Through a contracted vendor, certified coders review Level 4 and Level 5 claims for compliance with CMS and AMA guidelines. If a claim is downcoded, providers may appeal by submitting the medical records  via the Explanation of Benefits (EOB) address or through the Availity provider portal.

BlueCross BlueShield of Tennessee (BCBST)

BCBST launched its E/M Overcode Program in March 2025. This initiative evaluates high-level office visits to ensure alignment with accepted coding practices and identifies outlier providers with patterns of upcoding. Claims will not be adjusted below Level 3, and only providers identified as outliers will be affected. Appeals can be submitted following the guidelines outlined in the Provider Administration Manual.

Recommendations to Mitigate Impact

• Ensure thorough and accurate documentation for all E/M services
• Code to the highest specificity using appropriate ICD-10 and CPT codes
• Appeal promptly if the documentation and medical necessity substantiate the higher level