The California and Texas medical associations are urging Cigna to rescind a new policy they say will increase administrative burdens and create a barrier to appropriate reimbursement.
Beginning Oct. 1, Cigna’s new Evaluation and Management Coding Accuracy policy will review CPT evaluation and management codes 99204-99205, 99214-99215, and 99244-99245 for billing and coding accuracy. Some services may be adjusted by one level when guidelines are not met.
“To better align with the American Medical Association’s Evaluation and Management services guidelines, Cigna Healthcare will implement a new reimbursement and coding accuracy policy for E/M codes that are being inappropriately billed as a higher level,” a Cigna spokesperson told Becker’s. “This review will only apply to approximately 3% of in-network physicians who have a consistent pattern of coding at a higher E/M level compared to their peers. Claims will be individually reviewed for coding accuracy and payment may be adjusted by one level to meet AMA guidelines. Physicians may request reconsideration or appeal our decision if they feel the higher payment is appropriate.”
The California Medical Association said in an Aug. 20 news release that the new policy will require physicians who dispute the downcoding decisions to file an appeal and submit supporting medical records via fax, “creating substantial costs for both physicians and the plan itself.”
Texas Medical Association President Jay Shah, MD, said in a July 30 letter to the payer that automatic downcoding programs “place onerous administrative burdens on practices forcing them to fight for appropriate payment rates in an increasingly challenging environment for small and independent physician practices.”
“These measures also are counterproductive to the intent of recent revisions to E/M documentation and coding guidelines, which were meant to better align coding with patient-care delivery and to ease administrative burdens for physicians,” Dr. Shah said.
The California Medical Association added that since it appears Cigna will be reviewing higher-level E/M claims on the outset of receiving a claim, it presumes the assessments will be primarily based on a diagnosis billed on the submitted claim.
“While Cigna asserts that its policy is consistent with the American Medical Association’s CPT coding guidelines, its use of claim-level criteria to determine the appropriateness of E/M levels, without considering the documented total time or medical decision-making, appears inconsistent with both AMA and CMS guidelines,” the organization said.
The medical association said that Cigna should halt the policy and instead focus on educating coding outliers.
