CurrentUnitedHealthcarePolicy 2026R5033B

CMS 1500 Reimbursement — Anatomical and PCI Modifiers

Governs UnitedHealthcare reimbursement requirements for claims submitted on the CMS-1500 (or electronic equivalent), specifying required use of anatomical/laterality modifiers and PCI-specific anatomical modifiers for covered procedures across Commercial and Individual Exchange plans.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500 Reimbursement — Anatomical and PCI Modifiers

Policy CodePolicy 2026R5033B

Change TypeRevised (modifier requirements clarifiedPCI codes updated)

Effective Date

Next Review Date

Key ActionSubmit claims on CMS-1500 (or electronic equivalent) with accurate procedure codes and required anatomical or PCI modifiers.

SourceLink

POLICY UPDATE CHANGES

Policy language updated in Surgical and Radiological Codes section and requirement for anatomical modifiers clarified.

PCI Codes list was updated.

Attachment list of Bilateral 1 CPT Codes was removed in a recent update.

CMS-1500claim form governed

10000-69999; 70000code series requiring anatomical modifiers

5PCI modifiers

Multiple

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Modifier and Claim Handling Criteria

Modifier usage criteria

Covered when ALL of the following requirements are met:

ALL of the following

Surgical (CPT 10000-69999) and Radiological (CPT 70000 series) codes must be billed with the appropriate anatomical modifier for the procedure performed within an anatomical site.
PCI procedure codes must be reported with one of the five anatomical PCI modifiers (one per major coronary artery: left main, left anterior descending, left circumflex, right, ramus intermedius) to be considered for reimbursement.
Providers should code to the highest specificity when reporting laterality or anatomical detail (use digit-specific modifiers or F1–F9, FA, T1–T9, TA as applicable).

Claim handling and operational notes

Claims must be submitted on the CMS-1500 (or electronic equivalent) with accurate procedure codes and appropriate modifiers; UnitedHealthcare may exercise discretion in interpretation and application when evaluating modifier use.
If required anatomical or PCI modifiers are not reported, claims may be denied or adjusted for lack of highest specificity or to prevent duplicate/unbundled billing.
Use laterality/anatomical modifier mappings as documented (for example: RI mappings and TA mappings) to select the correct modifier for the billed service.

Procedure Codes, PCI Modifiers, and Laterality

PCI codes (examples)CPTCovered

92920	Percutaneous coronary intervention (various)
92924	Percutaneous coronary intervention (various)
92928	Percutaneous coronary intervention (various)
92933	Percutaneous coronary intervention (various)
92937	Percutaneous coronary intervention (various)
92941	Percutaneous coronary intervention (various)
92943	Percutaneous coronary intervention (various)
92973	Percutaneous coronary intervention (various)
92974	Percutaneous coronary intervention (various)
C9600	PCI HCPCS range (device/service related)

1–10 of 18

1/2

Surgical codes requiring anatomical modifiers (10000-69999)mixedCovered

No codes listed

Radiological codes requiring anatomical modifiers (70000)mixedCovered

No codes listed

inv-04: Laterality/highest specificity

RequirementProviders must code PCI procedures with one of the five anatomical PCI modifiers corresponding to the major coronary arteries (left main, left anterior descending, left circumflex, right, ramus intermedius).

Highest specificityProviders should code to highest specificity using digit-specific modifiers or F1–F9, FA, T1–T9, TA as applicable; claims may be denied if billed without highest specificity.

Denial riskClaims submitted for PCI without an anatomical PCI modifier may not be considered for reimbursement by UnitedHealthcare.

Claim Submission and PCI Modifier Requirements

Billing Rule

Claim submission and accuracy

Submit claims using the CMS-1500 form (or its electronic equivalent) and ensure procedure codes and any applicable modifiers are accurate and complete; UnitedHealthcare may exercise discretion in interpretation and may adjust or deny claims for inaccuracies.

Use CMS-1500 or electronic equivalent for all applicable services.
Report accurate procedure codes and append appropriate modifiers to clarify billed services.
Be aware UnitedHealthcare may exercise discretion to adjust or deny claims if submission is inaccurate.

Billing Rule

PCI procedure codes must include an anatomical PCI modifier

Report PCI procedure codes with one of the five descriptive anatomical PCI modifiers (corresponding to the five major coronary arteries) for the service to be considered for reimbursement.

Key Definitions

inv-07: Modifier

DefinitionModifier — a two-character code appended to a procedure or service code to clarify the billed service (for example, anatomical site or laterality).

PurposeUsed to increase coding specificity, prevent duplicate billing and unbundling, and improve reimbursement accuracy and editing consistency.

FormatAppended to the end of CPT/HCPCS procedure codes when appropriate to provide additional information about the service performed.

inv-08: Percutaneous coronary intervention (PCI)

DefinitionPercutaneous coronary intervention (PCI) — a nonsurgical procedure (coronary angioplasty) used to treat narrowed coronary arteries, including stent placement, atherectomy, and balloon angioplasty.

ScopeCovers procedures addressing stenotic coronary arteries associated with coronary heart disease.

Policy Version Changes

2026-02-01policy_version_changeLatest

Updated policy language in Surgical and Radiological Codes section; attachment list of Bilateral 1 CPT Codes removed.

2026-01-01policy_version_change

Attachments updated to Bilateral 1 CPT Codes list and PCI Codes updated.

2025-09-21policy_version_change