09/17/2025

ASCO's Efforts on Downcoding

Recently, ASCO has been made aware of concerns related to downcoding. Downcoding is the process in which a payer assigns a lower-level code to medical services, most recently evaluation and management visits, than those reported by the practitioner. ASCO has been monitoring this issue and evaluating potential advocacy efforts.

From a member education standpoint, Cigna is not the sole payer with downcoding policies, although currently, this policy is the one garnering attention due to its impending policy implementation. The following payers have downcoding policies already in place. These are the payers with policies that ASCO is aware of, however, this list may not be all-inclusive.

Some payers are using claims data, like diagnosis codes, to determine whether the reported E/M code is reflective of an appropriate level of service. Additionally, payers may also be using algorithms to target “outlier” reporting by physicians based on peer comparison. Payers are utilizing the following methods to downcode claims:

• Pending claims for medical records review,
• Denying with a level of service adjustment denial code, and
• Reimbursing the level of service reported with the lower-level rate. Knowing this information may assist practices in identifying affected claims.

ASCO is participating in a joint letter led by the American Academy of Orthopedic Surgeons which tackles downcoding policies from a multi-payer perspective and is addressed to CMS’ Center for Consumer Information and Insurance Oversight which oversees Affordable Care Act requirements and private insurance.

Please help MSHO in monitoring this situation by informing billing@msho.org about additional payer policies and practice impacts.