CurrentFlorida BluePolicy 23-081

Anatomical Modifier Requirement Policy

Defines which anatomical modifiers Florida Blue requires on claims, how they must align with diagnosis codes and coding rules, and applies to Florida Blue Commercial and Medicare Advantage providers submitting CMS-1500 claims or electronic equivalents.

Policy Summary

PayerFlorida Blue

PolicyAnatomical Modifier Requirement Policy

Policy CodePolicy 23-081

Change TypeNo material changes

Effective DateOct 19, 2023

Next Review DateN/A

Key ActionAppend required anatomical modifiers (E1-E4, TA-T9, FA-F9, RC/LC/LD/RI/LM, RT/LT) when clinically supported and ensure modifiers align with ICD-10 laterality.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

E1-E4, TA-T9, FA-F9, RC/LC/LD/RI/LM, RT/LTModifier sets required

Commercial & MALines of business

ICD-10 alignmentMust match laterality

59/XU/XS/XP/XEProhibited replacements

Eff 10/19/2023Policy timeline

Anatomical Modifier Billing Criteria

Policy Summary

PayerFlorida Blue

PolicyAnatomical Modifier Requirement Policy

Policy CodePolicy 23-081

Change TypeNo material changes

Effective DateOct 19, 2023

Next Review DateN/A

Key ActionAppend required anatomical modifiers (E1-E4, TA-T9, FA-F9, RC/LC/LD/RI/LM, RT/LT) when clinically supported and ensure modifiers align with ICD-10 laterality.

SourceLink

On This Page

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Anatomical modifier billing criteria

When to use anatomical modifiers and billing expectations:

Use anatomic-specific modifiers (E1-E4, TA-T9, FA-F9, RC/LC/LD/RI/LM, RT/LT) when clinically supported and when the procedure is performed unilaterally.

Anatomic modifiers appended to a procedure code must align with ICD-10 codes that specify laterality; do not append an anatomical modifier when the diagnosis code is unspecific for laterality where laterality is built into the ICD-10 description.

Do not use modifiers 59, XU, XS, XP, XE in place of an anatomical modifier.

Claims should be submitted with the correct anatomic modifier-to-procedure code combination; claims will be returned for reprocessing if a modifier does not match the anatomical site or if a necessary laterality modifier is omitted.

Services reported with anatomic modifiers are subject to multiple procedure reductions when applicable.

Claim Submission Modifier Requirements

Billing Rule

Append appropriate anatomical modifiers and match ICD‑10 laterality

Append the required anatomical modifier(s) to the procedure code when clinically supported, ensuring the modifier matches the anatomical site and aligns with any ICD‑10 laterality. Do not use modifiers 59, XU, XS, XP, or XE in place of an anatomical modifier. Claims may be returned for reprocessing if an appended modifier does not match the appropriate anatomical site or if a necessary laterality modifier is omitted.

Required anatomical modifier sets: E1–E4 (eyelids); TA–T9 (toes); FA–F9 (fingers); RC/LC/LD/RI/LM (coronary arteries); RT/LT (right/left).
Only use anatomic modifiers when clinically supported; do not append modifiers solely to bypass NCCI edits.
Anatomic modifiers appended to a procedure code must align with ICD‑10 codes that specify laterality; do not submit an anatomical modifier with an unspecific lateral diagnosis where laterality is built into the ICD‑10 description.

Anatomical Modifier Definition

Anatomical modifiers — definition and purpose

DefinitionTwo-character codes defined by the American Medical Association (AMA) CPT manual and CMS appended to CPT/HCPCS procedure codes to specify the anatomic area/part of the body and laterality.

PurposeProvide additional information about the service rendered to identify the highest level of specificity for coding and to facilitate correct claims adjudication and reimbursement.

ScopeUsed for fingers, toes, eyelids, coronary arteries, and right/left side of the body when submitting CMS-1500 claims or electronic equivalents for Florida Blue Commercial and Medicare Advantage.

Usage guidanceModifiers are appended to CPT/HCPCS codes and must be current and accurate to reflect the services provided; correct use is essential for correct reimbursement.

Regulatory sourceDefined by AMA CPT and CMS guidance for anatomical modifiers.

LT	Left side
RT	Right side
E1	Upper left eyelid
E2	Lower left eyelid
E3	Upper right eyelid
E4	Lower right eyelid
FA	Left hand, thumb
F1	Left hand, second digit
F2	Left hand, third digit
F3	Left hand, fourth digit

OpenPayer

Anatomical Modifier Requirement Policy

Anatomical Modifier Billing Criteria

Anatomical Modifiers and Descriptors

Claim Submission Modifier Requirements

Anatomical Modifier Definition