How do you inform a payer about the patient being fully responsible for all the charges? Through the GY modifier! You can communicate any situation with a specific modifier. These codes are the key to avoiding complicated issues or conflicts.
So, what exactly is the role of modifier GY? This two-character code indicates that a service is not covered by Medicare. In short, the GY modifier not only clarifies patient liabilities but also creates a formal record of Medicare’s denial. Today, we will explore this code in detail, starting with the description so you can receive complete payments.
GY Modifier – Description
GY modifier guarantees proper billing for non-covered services. In simple words? It indicates that a service is statutorily excluded. But what does this word actually mean? “Statutory” refers to written law. So, if a service or item is statutorily excluded, it simply means it does not qualify as a Medicare benefit.
Healthcare providers use the GY modifier to create automatic claim denials. Specifically, they use this code to notify insurance companies that they should deny the service because it is not included in the patient’s insurance plan. In short, the patient is responsible for the full cost.
Scenarios Where GY Modifier is Applicable
Do you know that statutorily excluded services are not the same as medically unnecessary procedures? Many practices fail to understand this difference and often use the modifier GY with services that Medicare might deem unreasonable. As a result, they struggle with late payments and patient conflicts.
You should be familiar with each ABN-specific modifier to avoid this problem. Look at the following scenarios to understand how to use the GY modifier accurately.
Eye Exams for Prescription Eyeglasses
Medicare is quite clear about its benefits, outlining all the non-covered items or services. Let’s start with an excluded routine exam! Suppose a 28-year-old woman accidentally breaks her eyeglasses. Before purchasing a new pair, she visits her ophthalmologist for a routine eye checkup (CPT code 92014) to see if her prescription has changed within the past three months.
Medicare does not cover eye exams for prescribing or changing eyeglasses. As a result, the eye doctor appends the GY modifier to CPT code 92014 to generate an automatic claim denial and charges the patient for the service.
Personal Comfort Items
We have provided an example of a non-covered service. Now, let’s consider an example of a non-covered item! Suppose a 29-year-old athlete recovering from a laminectomy — a major spinal surgery where a surgeon removes part of the vertebral bone — is admitted to a skilled nursing facility.
The patient requests entertainment items, like a radio or television, to pass the time. Since these devices are classified as personal comfort items, they do not qualify as Medicare-covered benefits. Therefore, the facility bills them with modifier GY.
Cosmetic Procedure (Liposuction)
Let’s explore another statutorily excluded procedure! Assume a 22-year-old woman aspires to become a model. She visits a cosmetology clinic to enhance her appearance. After a consultation, she decides to undergo liposuction to remove excess fat from her stomach.
The surgeon performs the procedure but knows that Medicare does not cover cosmetic procedures unless they are medically necessary. Therefore, he applies the GY modifier to CPT code 15877 to indicate that the service is statutorily excluded.
GY Modifier – Billing & Documentation Guidelines
Maintaining transparency with payers and patients is crucial when billing for any procedure. Therefore, you should follow these billing and documentation guidelines when using modifier GY.
Append Modifier GY to Statutorily Excluded Services or Items
The basic rule is to use GY modifier only with the appropriate CPT or HCPCS codes for services or items that Medicare never covers. These may include:
- Personal care items
- Services or items provided outside the U.S.
- Routine exams and supplies
- Cosmetic procedures
- Investigational devices
Do Not Issue an Advance Beneficiary Notice (ABN)
You might be familiar with the waiver of liability, commonly known as an ABN. This document is usually given to patients to inform them that Medicare may deny coverage for certain services. However, you do not need to issue this document with modifier GY.
Want to know why? Because patients are automatically liable for statutorily excluded services.
Maintain Clear & Complete Medical Records
Proper documentation is essential when using the GY modifier to inform Medicare that a service is explicitly not covered under its policy. This ensures transparency and prevents billing disputes. Therefore, clearly record every detail specifying why a service or item is not part of Medicare coverage.
Check Payer-Specific Guidelines
Before submitting a claim or billing a patient, always review payer-specific requirements to ensure compliance. In other words, you should check Medicare’s guidelines on modifier GY to confirm its proper usage.
Directly Bill the Patient
In addition to indicating that a service is statutorily excluded, the GY modifier also highlights that the patient is fully responsible for the charge. Therefore, you can bill the patient directly for the full cost of the service.
Avoid Basic Mistakes
Last but not least, use the GY modifier appropriately to avoid payment conflicts. Specifically, do not use this code with the following:
- Bundled procedures
- Add-on codes
Summary
To summarize, modifiers are essential for addressing different aspects of a situation. As one of the Medicare ABN-specific codes, a GY modifier is necessary for effective billing. It simply clarifies that the billed service does not qualify as a Medicare benefit. In technical terms, it is statutorily excluded.
In simple words, it means the financial responsibility for the provided procedure or item falls on the secondary payer or patient’s shoulders. We have covered the specifics of modifier GY, including detailed billing and documentation guidelines, so you can use it accurately.
Frequently Asked Questions
