The new Cigna E/M policy is creating a tremor in the medical field. This policy may reduce your reimbursements by 25 starting 1 October 2025 in case of insufficient documentation that supports your Evaluation and Management (E/M) codes. And you don t have to panic because this fact may be an advantage to the practices that can quickly change.
In this guide, we will share what this Cigna E/M policy actually conveys, how to prepare your documentation and why this transition is just one of the tendencies in the industry.
What is the Cigna E/M Policy?
Evaluation and Management Coding Accuracy Policy (R49), commonly referred to as the Cigna E/M policy, is another recently-introduced measure taken to increase control over reimbursements.
The following is what is evolving:
When the documentation within one of your bills does not justify the complexity billed, Cigna would automatically reserve the right of downgrading one level.
Consider billing 99215, and Cigna changing it to a 99214. You have just needlessly forfeited anywhere up to 25 percent of the reimbursement of that claim.
This is applied to the high-reimbursement codes that include the following:
- 9920499205 (New patient visits)
- 99214 99215 (Established patient visit)
- 99244-99245 (Consultation services)
Why the Cigna E/M Policy Matters
The evaluating and management of such visitors presents some of the top-earning codes in outpatient care. A loss of one level in such codes may cost several hundreds of dollars per patient visit, and this amount accumulates fast.
The Cigna E/M policy is aimed at the quality of documentation. When you are not ready, it is going to be delays, denials and even revenue contracts inward.
However, in the right hands your good documentation can not only save you your income but also save your practice audit-free.
How to Protect Your Reimbursements Under the Cigna E/M Policy
Here’s the good news: Cigna will honor your original coding level—if your documentation supports it.
So, how can you prepare? There are two compliant pathways under the Cigna E/M policy:
Pathway 1: Medical Decision Making (MDM)
Specify the three major MDM aspects and document them:
- Complexity of the problem: Evidently clarify that whether the problem is simple, low, moderate, or high complexity.
- Data Reviewed: Include lab tests and lab ordering, tests of imaging, and consultations reviewed.
- Risk of Complications:Explain the extent of the danger of treatment or outcome.
Example:
When using a 99215 code, the more documentation was made of high-level complexity, vast data review, and high risk (e.g., addressing chronic issues or administering high-risk drugs), the better.
Pathway 2: Time-Based Coding
The Cigna E/M policy accepts time-based coding—if documented properly.
Here are the minimum time thresholds:
- 99204 – 45 minutes
- 99205 – 60 minutes
- 99214 – 30 minutes
- 99215 – 40 minutes
- 99244 – 40 minutes
- 99245 – 55 minutes
Document all activities that count, such as:
- Face-to-face consultation
- Patient education
- Coordination with specialists
- Reviewing diagnostics
- Documentation and care planning
What Happens if You’re Not Ready?
Not adjusting to Cigna E/M policy is likely to lead to:
- Up to 25 percent loss of revenues per visit
- Slow payments and denials that are on the rise
- Dual Cigna and CMS audit flags
- Employee dissatisfaction and customer satisfaction
Those that disregard this policy will experience losses in the financial and operational front.
90-Day Action Plan to Get Compliant with the Cigna E/M Policy
Here’s a simple strategy to prepare before October 1, 2025:
Month 1: Audit
- Review past E/M documentation
- Identify under-documented claims
- Assess high-risk coding patterns
Month 2: Train
- Educate providers and medical assistants on new standards
- Reinforce time-based documentation rules
- Roleplay real documentation scenarios
Month 3: Test & Implement
- Use updated templates
- Implement real-time compliance checks
- Run trial audits before claim submission
Think Strategically: The Cigna E/M Policy is a Wake-Up Call
Instead of considering this burden, take this as a chance to improve quality. The truth is that proper documentation not only safeguards your revenue, but also benefits the patient care and makes you ready to face the policies that are set to be tougher in the future by all the payers.
That is not all about Cigna. UnitedHealthcare, Aetna, and co. are watching, and no doubt will comply.
Internal Optimization Tactics for Cigna E/M Policy Success
This is how intelligent practices are maximizing:
- Standardized Documentation Templates: Template format notes- MDM or time-based visits
- EHR Integration: Highlight field incomplete entries in real-time
- Documentation audits: Prohibit submission mistakes by conducting regular documentation requests EDIT
- Continuous Training: Prepare your staff and make them audit-friendly
- Patient-Level Flagging: Flag the complex patients that have advanced documentation requirements
Stats You Need to Know
It has been reported by CMS that more than 35 percent of the E/M claims are not properly coded.
- E/M services are on the list of the most popular categories of compliance investigation by the OIG (Office of Inspector General).
- The audits of Cigna have elevated by 35 percent per 2023, and the trend will continue to increase.
- Do not eliminate your practice as the next auditing statistic.
Final Thoughts: Your Documentation = Your Revenue Protection
The presence of Cigna E/M policy is something that clearly states that it is the age of documentation. Serious practices will treat it as follows:
- Maximize reimbursements
- Minimize den disappointments and appeals
- Establish financial sustainability as a long-term measure
- Clinical clarity Improve
Or, the question then must be, is your practice documentation-ready?
Take Action Now
Cigna’s new E/M policy goes into effect on October 1, 2025. That’s your deadline to:
- Build better documentation habits
- Educate your entire care team
- Implement systems that reduce risk
Protect your practice, your revenue, and your patients by preparing today.