Despite the Texas Medical Association asking for its repeal, Cigna’s new downcoding policy will take effect Oct. 1 – but the payer says the process will not apply universally to all physicians.
Starting Oct. 1, Cigna will begin to adjust certain higher-level evaluation and management (E/M) codes to a lower level – a practice also known as downcoding – when the payer determines the encounter criteria in the claim do not rise to the complexity required for the E/M code in the submitted claim. So far, the policy will apply to codes:
These codes represent professional claims for level 4 and 5 E/M services and indicate moderate or high-level complexity visits for new and established patients. Previously, Cigna planned to apply the policy to all physicians despite acknowledging it will impact approximately 3% of eligible claims. In a July advocacy letter to Cigna, TMA urged the payer to rescind the policy and instead educate the small number of physicians who make coding errors instead of subjecting all physicians to a “blanket downcoding initiative.”
In a response letter to TMA, Cigna stated: “We understand and appreciate that the vast majority of providers bill E/M claims consistently with their peers and within AMA billing guidelines. That’s why it’s important to note that this new reimbursement policy will not automatically result in an adjustment of reimbursement for E/M services for all providers.”
Cigna said the policy is “intended to place additional scrutiny only on claims billed by providers who[m] our records indicate as having a consistent pattern of coding at a higher E/M level compared to their peers. Per our initial analysis at the time of implementation, more than 97% of providers … will remain unaffected by this policy.”
The payer says it will identify which physicians will continue to undergo the downcoding policy based on claims submitted over a 12-month period, with a focus on those who consistently bill diagnosis codes and higher-level E/M codes not typically associated with complex cases requiring additional decision-making time. Each claim will be individually reviewed for coding accuracy, Cigna says.
The payer also confirmed the policy will allow physicians to request to be removed from the review process after they appeal five decisions. If the appeals review demonstrates that the physician billed appropriately at least 80% of the time, the physician can bypass the downcoding policy. This will apply to the individual physician, not the group level. Physicians meeting these criteria can request to have their claims bypassed from the policy by contacting Cigna.
However, the policy still represents a significant operational and financial challenge for impacted practices, says Marcial Oquendo Rincon, MD, chair of TMA’s Council on Socioeconomics, which provided input on TMA’s July letter and has been in ongoing communication with Cigna.
Dr. Oquendo is glad Cigna was receptive to TMA’s concerns – but still worries the policy could undermine clinical judgment and create a burdensome appeals process that adds to physicians’ already heavy workload.
Moreover, while Cigna says it has not yet established an electronic submission method –and still requires physicians to use fax machines to submit the required appeals documentation – the payer confirmed in its letter to TMA it is “actively exploring enhanced digital submission options” to streamline the reconsideration process and further reduce administrative burdens.
TMA, through its Council on Socioeconomics and Physician Payment Resource Center (PPRC), regularly meets with health plans and will continue to communicate with Cigna about its new policy and monitor its impact in Texas.
TMA staff also recommend practices review their electronic remittance advice to see if downcoding has occurred. Need assistance? Contact PPRC.
Alisa Pierce
Reporter, Division of Communications and Marketing
(512) 370-1469