A new Cigna policy could reduce physicians’ payment for high-level evaluation and management services, including complex care based on the encounter criteria in a submitted claim, resulting in the Texas Medical Association asking for its repeal.
Starting Oct. 1, Cigna will begin adjusting 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 does 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 indicate moderate or high-level complexity visits for new and established patients. In a July advocacy letter to Cigna, TMA urged the payer to immediately rescind the new policy.
Although it is unclear how the policy will be implemented, TMA underscored the importance of medical record reviews.
“The association vigorously opposes health plans relying exclusively on software, algorithms, or other methods to deny or downcode E/M services,” TMA stated. “Physicians are trained that the medical record is the cornerstone of quality care, documenting their clinical reasoning and reflecting the complexity and appropriateness of care provided. We, therefore, assert that Cigna has a responsibility to review the full medical record before denying or downcoding a claim.”
Some downcoding policies, particularly automatic downcoding, can add to physicians’ already substantial administrative burdens, fears Marcial Oquendo Rincon, MD, chair of TMA’s Council on Socioeconomics, which provided input on TMA’s July letter.
“Physicians’ documentation burdens – just to get paid for the work that we do – are already very high ... [Downcoding] requires even more effort. This is extra work for less payment,” the Dallas pediatrician said.
TMA also has concerns related to automatic downcoding, as reflected in its House of Delegates’ policy.
“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,” the association stated in its letter.
Cigna says its new policy will impact fewer than 3% of eligible claims – but the insurer still plans to apply the strategy to all physicians. TMA notes Cigna could educate the small number of physicians who make coding errors instead of subjecting all physicians to a “blanket downcoding initiative.”
Per Cigna, physicians impacted by the downcoding policy can make an appeal by submitting the full record of a patient’s visit to Cigna’s fax number at 833-392-2092. Claims will be adjusted if the original determination is overturned, and an updated explanation of payment will be issued, Cigna says.
However, physicians already pressed by financial constraints could face additional practice viability challenges while waiting for revenue held up by appeals processes, worries Round Rock family physician Tina Philip, DO.
“Physicians want to take care of all the patients we can, but if we can’t afford it, we can’t afford it,” the vice chair of TMA’s Council on Socioeconomics said. “So, what you end up seeing is patients losing out on [access to] care. It is very difficult to sustain a practice now ... and [downcoding] policies [can] affect, ultimately, the patients.”
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.
TMA’s PPRC is at the ready to help members with billing and coding issues. And for coding information and best practices, see TMA’s Billing, Coding, and Payment Resources page.
Alisa Pierce
Reporter, Division of Communications and Marketing
(512) 370-1469