In Chip Hart's latest blog post, the question is posed: Is the threat of automatic downcoding by payers — especially Cigna — as big a problem for pediatric practices as some fear? The Chip examines real data and industry reaction to understand what’s actually happening.
Chip acknowledges widespread concern around insurer downcoding — particularly Cigna’s prior announcement to automatically downcode evaluation and management (E/M) claims based on diagnosis codes alone, without reviewing physician documentation. Societies like the American Academy of Pediatrics pushed back hard, and Cigna initially backed off.
From Chip's analysis of PCC client ERA (electronic remittance advice) data:
-
Cigna downcoding appears rare. Most claim adjustments for Cigna clients haven’t involved significant E/M downcodes; many adjustments were simply modifier additions that ensure claims get paid.
-
Aetna downcoding has been more noticeable. Some practices experienced significant downcoding on Aetna E/M claims earlier in the year. These tend to correlate with common, generic ICD-10 codes (like cough or unspecified fever) that payers may question for higher-level visit codes.
Chip emphasizes that tracking downcoding is difficult because payers often do not use clear adjustment codes that flag when a higher-level code has been reduced. Practices must compare submitted and adjudicated CPT codes in remittance advice files to spot differences.
Bottom line: While automatic downcoding noise is real — and some payers are more aggressive than others — the “bogeyman” may be smaller in scale than perceived based on current PCC client experience. Practices experience some downcoding, but systematic, widespread reductions aren’t as clear or universal as the narrative suggests.
