Published 11/20/2025
It has recently come to the attention of AAOS that major payers, including Cigna, are implementing a new reimbursement policy to review professional claims billed with certain evaluation and management (E/M) codes. These payers have stated in their provider bulletins that they will automatically adjust to a lower-level E/M code until medical records are submitted to substantiate complexity and medical decision-making (MDM) or time associated with the reported E/M visit. However, the policy does not indicate how these determinations are made.
This policy has serious implications for orthopaedic surgeons. If an insurer automatically downcodes an E/M visit, the physician will have to decide whether to accept the lower payment or take on the administrative burden of providing further documentation and potentially appealing. Given that E/M services are some of the most commonly performed visits, the consequences of downcoding will quickly multiply.
Last month, AAOS led a letter with 20 other national medical specialty societies to Peter J. Nelson, JD, deputy administrator and director of the Center for Consumer Information and Insurance Oversight in the Centers for Medicare & Medicaid Services. AAOS is aware that state medical and orthopaedic societies are also reaching out to their state-level regulators to challenge this downcoding policy. AAOS will continue to monitor the situation and work with federal, state, and local partners in the physician community to ensure physicians are properly reimbursed for the care they provide to patients.
The letter reads as follows:
Dear Deputy Administrator and Director Nelson,
The undersigned physician organizations are writing to inform you of a troubling policy regarding Evaluation and Management (E/M) services. It has come to our attention that several payers will implement a new reimbursement policy to review professional claims billed with E/M codes 99204-99205, 99214-99215, and 99244-99245. We have seen provider bulletins stating that the policy is in alignment with the American Medical Association (AMA) E/M services guidelines, adjusting services by one level to reflect the appropriate reimbursement when AMA guidelines are not met. This policy is in fact against AMA’s E/M service guidelines. We have seen reports that payers including Aetna, Anthem, Cigna, Humana, and Sunshine (Centene) have already begun implementing this policy.
We are concerned about this policy which implies payers will automatically adjust the E/M CPT code level until medical records are submitted to substantiate the complexity and the medical decision-making (MDM) or time associated with the reported E/M visit. However, the policy does not indicate how these coding adjustment determinations are made. For example, what are the criteria which trigger such a denial? Is downcoding of E/M charges based solely on the complexity of the diagnosis codes submitted? These questions raise many concerns for us as physician notes are not typically sent with E/M visits.
Our organizations are concerned about the unwarranted burden to physicians and their staff, and ultimately barriers to patients’ access to quality care. This coding-adjustment practice sets a dangerous precedent and raises several issues regarding the legality of this type of policy. We are also concerned that this policy will lead to under-coding to avoid having claims adjusted. There are several factors that account for high-level E/M visits such as the decision for surgery and ordering and interpretation of images. Physicians should be reimbursed appropriately for this work.
We thank you for your attention to this matter and stand ready to work with you on a solution that allows for oversight while ensuring proper payment to physicians for the care they provide to patients. Please do not hesitate to reach out to Lori Shoaf, vice president, Office of Government Relations at AAOS (shoaf@aaos.org), to discuss this issue further.
Sincerely,
American Academy of Family Physicians
American Academy of Neurology
American Academy of Ophthalmology
American Academy of Otolaryngology–Head and Neck Surgery
American Association of Neurological Surgeons
American Association of Oral and Maxillofacial Surgeons
American Association of Orthopaedic Surgeons
American College of Emergency Physicians
American College of Obstetricians and Gynecologists
American College of Physicians
American College of Rheumatology
American College of Surgeons
American Gastroenterological Association
American Geriatrics Society
American Osteopathic Association
American Society of Cataract and Refractive Surgery
American Urological Association
Association for Clinical Oncology
Congress of Neurological Surgeons
North American Spine Society
Renal Physicians Association
The Society of Thoracic Surgeons