What Is the GY Modifier Used For in Medical Billing?
Understand the GY modifier in medical billing. Learn why it's used for non-covered services and its impact on patient costs.
Medical billing modifiers are two-character codes appended to procedure codes to convey additional information about the services healthcare providers render. The GY modifier signals that a service or item is not covered by Medicare.
What the GY Modifier Represents
The GY modifier is a Healthcare Common Procedure Coding System (HCPCS) modifier. Its primary function is to indicate that a specific item or service is statutorily excluded from Medicare coverage or does not meet the definition of a Medicare benefit. This means federal law or Medicare policy explicitly states that Medicare will not pay for these services under any circumstances, irrespective of medical necessity.
By attaching the GY modifier to a claim, healthcare providers formally notify Medicare that the service rendered is not a covered benefit. This action is intended to trigger an automatic denial from Medicare. The use of this modifier clarifies that the provider understands the service is non-covered and that the financial responsibility for the service will fall to the patient or another payer.
Situations for GY Modifier Use
The GY modifier is applied in circumstances where services are statutorily excluded from Medicare benefits. Common examples of services where the GY modifier is appropriately used include routine eye exams, especially those not related to a specific medical condition, and cosmetic surgical procedures.
Other instances involve services like most routine dental care, including cleanings and fillings, and certain personal comfort items. Massage therapy and specific types of chiropractic maintenance care also fall under services typically excluded by statute.
Patient Financial Implications
When a GY modifier is used on a medical claim, it immediately signals that the patient will be responsible for the cost of the service. The provider intends to bill the patient directly for these services.
In many situations involving non-covered services, healthcare providers use an Advance Beneficiary Notice of Noncoverage (ABN).
An ABN is a written notice given to Medicare beneficiaries before services are provided when Medicare is expected to deny payment. This document informs the patient that Medicare will likely not pay for the service and outlines their financial responsibility.
The ABN typically includes a description of the service, the reason Medicare is not expected to cover it, and the estimated cost. Patients then have options to either accept financial responsibility and receive the service, or refuse the service.
It is important to note that for services indicated by the GY modifier, an ABN is generally not required because these services are never a Medicare benefit, as opposed to services that might be denied due to lack of medical necessity.