Why did Cigna pay my 99215 as a 99214? Most likely the Evaluation and Management Coding Accuracy policy (R49), effective for dates of service on or after October 1, 2025. It lets Cigna lower a level 4 or 5 E/M claim by one level when the claim data does not appear to support the level billed. Aetna's Claim and Code Review Program runs a similar review on level 4 and 5 visits.
Outpatient psychiatry bills a lot of 99214 and 99215, often with a psychotherapy add-on. That profile makes psychiatrists more likely than average to land in these reviews. A year in, here is what the policies do and what holds up on reconsideration.
How Cigna R49 works
- Codes in scope: 99204, 99205, 99214, 99215, 99244, and 99245.
- Who it applies to: in-network clinicians Cigna identifies as having a consistent pattern of higher-level E/M coding compared with peers. Cigna said under 3% of clinicians would see adjusted claims at launch.
- What happens: individual claim lines can be reduced by one level, for example 99215 to 99214, or 99214 to 99213.
- Reconsideration: submit the full encounter record. If it supports the original level through medical decision making or time, Cigna reprocesses at the billed level.
- Bypass: clinicians with several adjusted claims who believe their coding is accurate can ask Cigna to remove them from the policy, supported by records.
How Aetna's review works
Aetna's Claim and Code Review Program uses certified coders to compare level 4 and 5 E/M claims against AMA and CMS guidelines. Claims judged unsupported can be revised downward. Appeals go through Availity or the address on the explanation of benefits, with the medical record attached.
The documentation that holds a level
Since 2021, office E/M levels are chosen by medical decision making (MDM) or total time on the date of the encounter. For established patients, 99214 requires moderate MDM or at least 30 minutes; 99215 requires high MDM or at least 40 minutes.
Psychiatry has one rule that trips up a lot of notes: when you bill a psychotherapy add-on (90833, 90836, 90838) with an E/M, time spent on psychotherapy cannot count toward E/M time. In practice, that means E/M + psychotherapy visits should usually be leveled on MDM, and the note should show the psychotherapy time separately.
What makes MDM visible in a psychiatric note:
- Problems. Name each condition and its status: "MDD, recurrent, worsening on current regimen" reads as a chronic illness with exacerbation. "Depression, follow-up" reads as stable.
- Data. List what you reviewed: labs, outside records, rating scales with scores, collateral from family, PDMP review.
- Risk. Prescription drug management is moderate risk on its own. Document the decision, including what you weighed: dose changes, side effects, interactions, monitoring. Drug therapy requiring intensive monitoring for toxicity, such as lithium or clozapine, supports high risk. So does a decision about hospitalization.
- Suicide and safety assessment. When risk is elevated, document the assessment and the decision you made about level of care. That supports high complexity.
- Psychotherapy as a separate block. Start and stop time, modality, and the focus of the session, distinct from the medication management.
A workflow for adjusted claims
- Track every downcode by payer and code. Look for the adjustment reason on the remittance, and compare paid code to billed code automatically.
- Send reconsiderations in batches with complete encounter notes. Partial notes get denied.
- After several overturned adjustments, request a bypass from Cigna with those records.
- Audit a sample of your own notes each quarter. If a reviewer would struggle to see moderate or high MDM, the template is usually the problem, and fixing it once fixes every future note.
The bottom line
Accurate 99214 and 99215 coding is well supported by the AMA guidelines for most psychiatric medication management. These policies reward notes that make the decision making easy to see. A short, structured assessment and plan, with psychotherapy time documented on its own, protects the level and speeds up any reconsideration.