As we enter October, several major payor updates are taking effect that could directly impact how your practice bills and gets reimbursed.
Cigna Healthcare – New Reimbursement Policy (R49)
Effective October 1, 2025, Cigna Healthcare will implement its new reimbursement policy, Evaluation and Management Coding Accuracy (R49). This policy will review professional claims billed with CPT codes 99204–99205, 99214–99215, and 99244–99245 for coding accuracy.
While several professional organizations have objected, the policy is set to move forward as planned. Cigna may downcode one level before reviewing medical records — even though they report only 3% of providers as overcoding.
If your claim is adjusted and you believe your documentation supports the original level of service:
- Submit the complete medical record for the date of service to Fax: 833-392-2092.
- Include the patient’s name and date of birth on every page.
If Cigna overturns its determination, the claim will be readjusted and a new explanation of payment will follow.
If not, you can still proceed with an administrative appeal.
Medicare – End of Certain Telehealth Flexibilities
The Full-Year Continuing Appropriations and Extensions Act, 2025 (Section 2207) extended many telehealth flexibilities only through September 30, 2025. Unless Congress passes a continuing resolution (CR), pre-COVID statutory limitations will once again apply.
This means:
- Geographic and location restrictions return.
- Only certain practitioners can deliver telehealth services.
Billing guidance for 2025:
Continue using the POS you would for an in-person visit.
- POS 02 – Patient not in their home.
- POS 10 – Patient in their home (reimbursed at the non-facility rate).
At Total RCM Solutions, we continuously monitor payer changes to keep your practice compliant and financially secure. Stay tuned for further updates as more details unfold.