July Industry Notes: Cigna Reimbursement Policy 

Notification: Effective 10/01/2025 Cigna has developed a new reimbursement policy, Cigna may adjust the E/M CPT® code 99204- 99205, 99214-99215, 99244-99245 to a single level lower when the encounter criteria on the claim does not support the higherlevel E/M CPT® code reported. 

Cigna will reimburse claims for professional services submitted in accordance with coding and documentation guidelines established by the AMA within the Current Procedural Terminology (CPT®) Evaluation and Management coding guidelines and guidelines around additional services provided at the time of the encounter. Providers are also expected to adhere to the ICD-10 CM coding guidelines when identifying a diagnosis for the treatment of a condition.  

Cigna may adjust the E/M CPT® code 99204- 99205, 99214-99215, 99244-99245 to a single level lower when the encounter criteria on the claim does not 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.  

When a code level has been adjusted and, subsequently, medical records are submitted that substantiate the complexity and Medical Decision Making (MDM) or time associated with the reported E/M CPT® code level, the code will be reimbursed at the level initially submitted.