More payers implementing evaluation and management code level reviews
Several insurance payers are expanding pre-payment claim reviews for higher-level evaluation and management (E/M) services. These reviews often target level 4 and 5 visits and may result in downcoding.
UnitedHealthcare’s Smart Edit and Elevance Health’s (formerly Anthem) E/M Leveling program have been in place for several years. Now, additional payers are adopting similar programs.
The AADA continues to engage with payers to address program criteria, processes, and concerns arising from these edits. After a detailed review of these editing programs, the Academy established the following about the payer E/M editing programs.
Aetna
Expanded its E/M review program from 12 pilot states to all Aetna commercial states (except Louisiana).
Plans to extend the program to Aetna Medicare Advantage plans in late 2025.
Reviews level 4 and 5 E/M claims from physicians identified as outliers and applies prepayment edits as deemed appropriate.
Inclusion in the program typically lasts for one year; however, practices may seek early removal from the program if they successfully appeal 75% of downcoded claims. Additional program details are available on Availity, Aetna’s portal for health care professionals.
Cigna
Effective Oct. 1, 2025, Cigna will implement a new policy to downcode E/M codes 99204- 99205, 99214-99215, and 99244-99245 by one level if documentation does not support the reported code.
The AADA met with Cigna to review its Evaluation and Management Coding and Accuracy (PDF) policy.
Physicians can call 800-88CIGNA (800-882-4462) to confirm if they are included in the review program, request reconsideration of their downcoded claims, or seek removal from the program review.
Appeals may also be submitted with supporting documentation if reconsideration is denied.
Full details, including FAQs, about the Reimbursement Policy Commercial - R49 Evaluation and Management Coding and Accuracy update are available on the Cigna for Health Care Professionals (CignaforHCP.com) portal (login required) and the Provider Newsroom.
Cigna is encouraging clinicians to work with their service representatives to access the most current guidance.
Blue Cross Blue Shield of Massachusetts
Effective Nov. 3, 2025, BCBSMA will expand its pre-payment claims editing to review level 4 and 5 E/M services.
Claims will be assessed to confirm that the level of service is supported by the severity of the patient’s condition. Claims that do not meet criteria may be downcoded to a lower E/M level.
The Academy is currently working to schedule a meeting with the carrier to discuss the program further and address physicians’ concerns.
Important note
For both Aetna and Cigna, practices will not receive separate notifications when claims are downcoded. The only way to identify changes in payment rates is by carefully reviewing EOBs and remittance advice for language such as: “codes on the claim do not support the level of service reported.”
What dermatology practices should know
The AADA opposes inappropriate payment reductions for services that are appropriately documented and reported, and is concerned about payer programs that create unnecessary administrative burden for practices forced to appeal inappropriately downcoded claims.
Recommendations for practices
It is important for physicians and non-physician clinicians to code encounters to the highest level of specificity and ensure proper documentation in the medical record. The overuse of unspecified ICD-10-CM codes and inadequate documentation to support the level of service can result in downcoding, which can impact claim reimbursement.
To help ensure proper claim processing, dermatology practices should:
Use the most specific ICD-10-CM codes to support clinical findings. Avoid using unspecified codes unless no other relevant diagnosis code is available;
Document the E/M encounter clearly and thoroughly to support the level of service reported; and
Ensure medical necessity is demonstrated in the medical record and that it supports the reported service.
Member support
For coding and documentation questions, contact the Academy’s coding experts at coding@aad.org.
To report payer issues, contact privatepayer@aad.org.
The AADA encourages its members to access and review Academy coding resources on E/M guidelines to strengthen claim defensibility.
