When dealing with medicare claims, it’s essential to communicate clearly with payers about patient responsibilities. One simple way to do this is by using the GY modifier. This two-character code helps notify Medicare that a service or item is not covered, ensuring billing accuracy and preventing confusion.
But what does the GY modifier actually do? It indicates a service is excluded by statute, i.e., it is not a Medicare benefit under the statute. This modifier will cause Medicare claims to be denied, pushing financial responsibility onto the patient automatically. In this guide, we will dissect its function, application scenarios, and correct billing protocols so you will be able to go through the process with assurance.
What Does the GY Modifier Mean?
The GY modifier is applied to denote that a service is not Medicare-covered at all. That is, the service is legally excluded, and not merely because it is not medically necessary. When providers append the GY modifier to a claim, they are, in effect, requesting an automatic denial by Medicare. This serves to indicate that the patient will have to pay the entire cost of the service.
When to Use the GY Modifier
Numerous providers incorrectly apply the GY modifier to services that Medicare can consider medically unnecessary, resulting in payment disputes and patient confusion. To avoid this, it is essential to know the appropriate circumstances where the GY modifier is used.
Example Situations for the GY Modifier
Routine Eye Exams for Prescription Eyeglasses
Medicare does not pay for routine vision tests associated with prescribing or renewing eyeglasses. Let’s say a 28-year-old female patient cracks her glasses and makes an eye exam appointment (CPT code 92014) to renew her prescription. Because Medicare does not cover these tests, the ophthalmologist attaches the GY modifier so that the claim will automatically be denied and the patient must pay.
Personal Comfort Items
A 29-year-old athlete who underwent spinal surgery is admitted to a skilled nursing facility. For comfort during his stay, he wants personal items such as a radio or television. As Medicare does not include entertainment items in its coverage, the facility uses the GY modifier when billing the non-covered items, transferring the cost to the patient.
Cosmetic Procedures (Liposuction)
A 22-year-old female patient who wants to pursue a career in modeling goes to a clinic for liposuction (CPT code 15877) to get rid of excess fat. Medicare does not cover cosmetic procedures unless medically necessary, so the surgeon adds the GY modifier to state that the service is statutorily excluded. The patient has to pay out of pocket.
How to Properly Bill with the GY Modifier
It is imperative to ensure transparency in medical billing, particularly with non-covered services. Use the following best practices in applying the GY modifier correctly:
1. Use the GY Modifier Only for Statutorily Excluded Services or Items
Use the GY modifier only for CPT or HCPCS codes that are never covered by Medicare, such as:
- Personal care items
- Services rendered outside of the U.S.
- Routine exams and medical supply items
- Cosmetic procedures
- Experimental or investigational devices
2. Do Not Issue an Advance Beneficiary Notice (ABN)
An ABN (Advance Beneficiary Notice) is normally employed to caution patients that Medicare will deny a claim. An ABN, however, is not required when employing the GY modifier since Medicare excludes the service by law, and thus the patient is automatically liable.
3. Keep Thorough Documentation
Precise record-keeping is necessary when billing with the GY modifier. Document clearly, the reason why the service is not covered under Medicare policy to avoid billing disputes and maintain transparency.
4. Verify Payer-Specific Guidelines
Medicare has strict guidelines for modifier use, but private insurance companies might have varying policies. Prior to submitting a claim, check payer-specific guidelines to ensure compliance and prevent claim rejections.
5. Bill the Patient Directly
Because the GY modifier indicates that Medicare will deny the claim, the provider may bill the patient directly for the service. This prevents delays and informs the patient of his/her financial responsibility ahead of time.
6. Prevent Common Errors
Applying the GY modifier incorrectly can create billing issues. Do not use it for:
- Bundled procedures
- Add-on codes that rely on a primary service
Conclusion
The GY modifier is a necessary medical billing tool for providers to clarify that a service is not covered under Medicare. It will cause claims to be denied automatically, transferring the financial burden to the patient or secondary payer.
By learning about its proper application and adhering to correct billing procedures, you are able to enhance payment effectiveness and eliminate disputes. With this knowledge on how the GY modifier functions, XyberMed can correct claim processing and hassle-free financial transactions for you.