Cigna E/M Coding Accuracy Policy (R49)

Cigna’s New E/M Coding Accuracy Policy (R49): What Providers Need to Know 

At a Glance 

Why Cigna Is Implementing R49 

Evaluation and Management (E/M) services represent one of the largest categories of professional claims in Medicare and commercial insurance. CMS and the Office of Inspector General (OIG) have repeatedly flagged E/M coding as an area with high error and overbilling risk [3]. 

Cigna states the new policy is designed to improve coding accuracy, prevent inappropriate upcoding, and promote fair reimbursement while avoiding claim payment delays. 

How the Policy Works 

Adjustment mechanism 

Under R49, if submitted claim information does not substantiate the reported E/M level, Cigna may adjust the claim down by one level (for example, from 99215 to 99214). This applies only to individual claim lines, not across all services billed by a provider [1]. 

Prompt payment and reconsideration 

Unlike traditional audits that delay payment pending documentation, Cigna indicates it will pay promptly at the adjusted level and clearly mark the adjustment on the Explanation of Payment (EOP). Providers may then submit the full encounter record; if documentation supports the originally billed level, reimbursement will be corrected. Providers also retain the right to pursue an administrative appeal [1][2]. 

Bypass process 

Providers with five or more adjusted claims may request a policy bypass. Cigna will review a sample of claim histories; if at least 80% of reviewed claims support the billed level, bypass will be granted. This process is designed to remove compliant providers from ongoing claim adjustments [1]. 

Methodology and Provider Impact 

Cigna developed a screening process to identify outlier providers. Diagnoses such as “earache” or “sore throat” are cited by Cigna as examples of conditions that typically do not justify high-level coding. Providers who consistently bill higher-level E/M codes for these routine diagnoses relative to peers may be flagged for inclusion under the policy [2]. 

Cigna’s internal analysis estimates that nearly 99% of providers will not be affected, including about 97% of frequent level-4/5 billers [2]. These figures are based on Cigna’s data and may not reflect independent national patterns. 

Industry and Regulatory Context 

Regulators and payers have increasingly scrutinized E/M coding. OIG and CMS have identified high error rates in E/M services through improper payment audits [3]. Multiple commercial payers, including Aetna and UnitedHealthcare, have piloted or expanded claim-edit programs, signaling a trend toward earlier claim-level checks, though approaches differ by payer [4]. 

Cigna argues this approach reduces administrative burden by avoiding prepayment holds. However, medical associations have raised concerns. For example, the California Medical Association has urged Cigna to withdraw R49, citing potential legal issues and added administrative load for practices tasked with frequent reconsiderations [5]. 

Implications for Providers 

Cigna’s R49 policy represents a shift in how commercial payers address E/M coding accuracy—favoring real-time claim adjustments over retrospective audits. While Cigna positions the policy as efficient and minimally disruptive, provider groups caution that it could increase administrative workload and raise compliance risks. 

Healthcare organizations should review the details of R49, educate coding staff, and prepare documentation workflows that support reconsideration requests. Monitoring industry reactions and similar payer initiatives will be key to understanding whether this model expands more broadly. 

References