Anatomical Modifiers - Fingers and Toes

Policy Update #: POLANAMOD080125

Effective Date: August 1, 2025

Current State: Sentara Health Plans follows the Centers for Medicare and Medicaid Services (CMS) guidance for anatomical modifiers. According to the CMS claims processing manual, “when certain component codes or mutually exclusive codes are appropriately furnished, such as later on the same day or on a different digit or limb, it is appropriate that these services be reported using an HCPCS code modifier.”

Future State: Enforcement of correct coding guidelines, regarding anatomical modifiers, is an important aspect of payment integrity code editing. 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. Therefore, Sentara Health Plans will be deploying an edit that reviews surgical procedures on the foot and toes (code range 28001-28899*) and the hand and fingers (code range 26010-26989*) when they are not reported with the appropriate anatomical modifier. Note: *included codes must represent a digit.

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Anatomical Modifiers- Fingers and Toes - Policy Update