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Professional claims for evaluation and management services
Act
immediately
Effective date
Oct 1, 2025
Identified
Jun 18, 2026
Summary
Cigna Healthcare implemented a new reimbursement policy (R49) that automatically adjusts high-level E/M codes to lower levels for providers identified as having coding patterns inconsistent with diagnosis complexity. Claims are paid at the adjusted level but providers can request reconsideration with clinical documentation.
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What to do
immediately · 4 steps
01Review all level 4 and 5 E/M coding patterns to ensure alignment with AMA guidelines and diagnosis complexity.
02Monitor EOPs starting November 21, 2025 for adjusted claims through CignaforHCP.com portal.
03Prepare to submit clinical documentation for reconsideration requests via secure fax 833.392.2092 or online portal.
04Ensure providers document medical necessity thoroughly for complex cases to support high-level E/M codes.
Codes mentioned
992049920599214992159924499245
Original notice
Professional claims for evaluation and management services
providernewsroom.com · Always check the source before changing claims.
Related changes
See all Cigna changes →2025 Clinical, reimbursement, and administrative policy updatesHighEffective Mar 15, 2025 · Claims & BillingSummary of Provider Newsroom U.S. commercial medical articlesHighEffective Oct 1, 2025 · GeneralSummary of Provider Newsroom U.S. commercial medical articlesMediumEffective Oct 1, 2025 · GeneralNew Reimbursement Policy for Professional Evaluation and Management Services Claims effective October 1, 2025MediumEffective Oct 1, 2025 · CodingBrowse every Cigna change in the policy list