The insurance giant's new approach to combating E/M upcoding creates more problems than it solves

Effective October 1, 2025, Cigna implemented a controversial new reimbursement policy that automatically downgrades higher-level Evaluation and Management (E/M) codes based solely on claim data without ever reviewing the clinical documentation that would justify the coding decision. While the intent to address widespread upcoding issues is understandable, Cigna's heavy-handed approach represents a fundamental misunderstanding of how to create meaningful change in healthcare documentation and coding practices.

The Problem is Real

Let's be clear: E/M upcoding is a legitimate concern. As someone who conducts extensive E/M reviews, I see it daily—documentation that's nothing more than elaborate copy-paste jobs masquerading as comprehensive patient encounters. The Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG) have repeatedly identified E/M services as among the most frequently miscoded, and physicians have indeed increased their reporting of higher-level codes since the 2021 guidelines took effect.

The clinical reality is sobering. Too many providers select codes based on wishful thinking rather than actual complexity. I regularly encounter documentation where a routine follow-up for stable hypertension is coded as 99214 or 99215, supported by nothing more than templated text that bears no resemblance to the actual patient encounter.

The Stick Approach: Necessary but Insufficient

Healthcare needs accountability mechanisms—the proverbial "stick" that encourages providers to improve their documentation and coding accuracy. The question isn't whether oversight is needed; it's how that oversight should be implemented.

Effective accountability requires:

• Education before punishment: Providers need clear guidance on documentation requirements
• Transparent criteria: Clear explanations of why codes are being adjusted
• Opportunity for improvement: Systems that allow providers to learn from mistakes
• Proportional responses: Consequences that match the severity of the issue

Why Cigna's Approach Misses the Mark

Cigna's policy of automatically downgrading codes fails on multiple fronts:

1. Administrative Burden Without Value

The policy creates a bureaucratic nightmare where providers must now appeal legitimate claims, adding administrative costs that ultimately get passed to patients. Good providers who code correctly will spend countless hours fighting downgrades, taking time away from patient care.

2. Guilty Until Proven Innocent

By defaulting to downgrades and requiring medical records to justify the original coding, Cigna assumes provider guilt. This approach damages the already strained payer-provider relationship and treats all providers as potential fraudsters.

3. No Real Learning Opportunity

Automatic downgrades don't educate providers about what went wrong. Without specific feedback on documentation deficiencies, providers can't improve their practices. This policy punishes without teaching.

4. Inconsistent Review Standards

Who at Cigna is reviewing these codes? What are their qualifications? Without transparency in the review process, providers have no way to understand or challenge the criteria being used.

What Should Happen Instead

Both sides need to step up:

Providers Must Do Better

• Stop the copy-paste culture: Document what actually happened during the encounter
• Understand the guidelines: The 2021 E/M changes aren't that complicated—learn them
• Match complexity to coding: If your medical decision-making was straightforward, don't code it as high complexity
• Invest in training: Poor documentation habits cost money in the long run

Insurers Need Smarter Solutions

• Educational interventions first: Target providers with concerning patterns for education before penalties
• Transparent review processes: Publish clear criteria for code adjustments
• Collaborative improvement: Work with provider organizations to improve documentation standards
• Proportional responses: Differentiate between obvious fraud and documentation deficiencies

The Relationship Damage

Cigna's approach fundamentally misunderstands how E/M coding works. You cannot determine the appropriateness of an E/M code without reviewing the actual clinical encounter - the medical decision-making process, the complexity of problems addressed, the time spent, and the clinical reasoning involved. None of this information appears on a claim form.

By making coding decisions without clinical context and forcing providers to appeal with documentation to get appropriate reimbursement, Cigna has created a system that assumes all higher-level coding is inappropriate until proven otherwise - without ever looking at the proof that matters.

A Better Path Forward

The solution isn't to abandon oversight but to implement it intelligently:

1. Risk-based auditing: Focus intensive review on providers with statistical outliers in coding patterns
2. Educational partnerships: Work with medical societies to improve documentation training
3. Clear feedback mechanisms: Provide specific guidance on why codes are adjusted
4. Graduated responses: Start with education, escalate to monitoring, and reserve penalties for persistent problems

The Bottom Line

Cigna's policy addresses a real problem with a poorly conceived solution. Yes, providers need to improve their documentation and coding accuracy—the current state of E/M documentation in many practices is frankly embarrassing. But insurers who want meaningful change need to approach this as partners in improvement, not adversaries in combat.

The healthcare system doesn't need more administrative friction. It needs collaborative solutions that improve documentation quality while preserving the trust necessary for effective patient care. Cigna should rethink this policy before it further damages provider relationships and creates new barriers to appropriate patient care.

The author conducts extensive E/M documentation reviews and has seen firsthand both the problems with current coding practices and the challenges providers face in navigating insurance requirements.