MedPage Today December 12, 2025
‘This is wrong and should be illegal,’ one provider group says
Several insurers are automatically downcoding — and, therefore, paying less for — claims for non-procedural office visits, a practice that provider groups said is unfair and may be anticompetitive.
The claims involved are mostly “evaluation and management” (E/M) visits for established patients. In an announcement, Cigna noted that, under one automatic downcoding program implemented on Oct. 1, the insurer may adjust the E/M Current Procedural Terminology (CPT) codes 99204-99205, 99214-99215, and 99244-99245 “to a single level lower when the encounter criteria on the claim does not support the higher-level E/M CPT code reported.” For example, a claim may be adjusted from 99215 to 99214, or from 99214 to 99213.
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