CMS Guidelines for Anatomical Modifiers

Policy Update #: POLCMSANAMOD092125

Effective Date: September 21, 2025

Current State: N/A

Future State: Sentara Health Plans will apply a claims edit to deny radiology procedure codes requiring anatomical modifiers when the modifier is not submitted on the claim. Without the proper anatomical modifier applied to the procedure code, there is a risk of duplicate claims payment, incorrect procedure-to-procedure bundling, incorrect frequency limitations, and unnecessary medical record review.
Sentara Health Plans follows The Centers for Medicare & Medicaid Services (CMS) guidelines for anatomical modifiers. According to the CMS Claims Processing Manual, “when certain radiology codes are appropriately furnished, it is appropriate that these services be reported using a procedure code modifier.”
Enforcement of correct coding guidelines, regarding radiology anatomical modifiers, is an important aspect of payment integrity code editing.

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