Cigna Healthcare Implements New Policy Targeting E/M Coding

Cigna Healthcare implemented a new medical reimbursement policy — Evaluation and Management (E/M) Coding Accuracy (R49) — intended for providers that consistently bill higher-level codes for routine services compared to their peers.

Claims now are reviewed for discrepancies between billed levels and supporting documentation. They will be paid promptly at an adjusted level (no more than one level lower), with changes noted on the Explanation of Payment (EOP). Providers can submit clinical documentation for reconsideration. If documentation supports the original level, reimbursement will be corrected. Providers may also appeal upheld decisions.

Cigna estimates that the new policy will only impact approximately 3% of in-network providers who regularly bill levels 4 and 5 codes. The other 97% of providers that regularly bill these codes will not be affected by the change. For the 3% of providers flagged for higher-than-average coding, adjustments will apply only to individual claims where documentation does not support the billed level.

ACR^® does not anticipate this new policy will have a large impact on radiology practices, but members who have questions or concerns are urged to contact Katie Keysor, Senior Director of Economics and Health Policy.