An insurance company is introducing a new threat to American medicine [View all]

Complexity in medicine cannot be reduced to a billing code

"On Oct. 1, Cigna will roll out a policy that tracks how physicians bill. It will flag those who submit a higher proportion of level four or level five visits — which get reimbursed at a higher rate — than their peers. For doctors placed under this extra scrutiny, certain claims at those higher levels may be adjusted down by one level if the billing details do not appear to justify the service. The affected codes include 99204–99205 (new patient, office/outpatient), 99214–99215 (established patient, office/outpatient), and 99244–99245 (consultations).

Cigna says the goal is to fight upcoding and billing abuse, arguing that some physicians bill for more complex visits than were actually provided, such as charging for a 40-minute encounter when the visit lasted only 10 minutes, and that these patterns drive unnecessary costs for patients and employers.

But coding is not based on time alone. Under current rules, physicians can bill according to either total time or the complexity of medical decision making. That means a physician who legitimately spends half an hour or more untangling multiple conditions, reviewing medications, and coordinating care could still be flagged as an outlier, triggering payment reductions and extra administrative work even when the documentation supports the higher code.

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Complexity in medicine cannot be reduced to a billing code. A patient with hypertension, diabetes, or depression may look “routine” on paper, yet the visit may involve reconciling medications, coordinating referrals, addressing side effects, screening for complications, and navigating barriers like cost or insurance approvals. That is not a three-minute problem; it’s a 30 to 40-minute conversation."

https://www.statnews.com/2025/09/29/cigna-downcoding-prior-authorization-doctors-bureaucracy/