HCPCS Modifier GY

Description
Item or services statutorily excluded does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit.

Guidelines/Instructions

  • Submit HCPCS modifier GY with items or services that are statutorily excluded or those that do not meet the definition of any Medicare benefit
  • Examples of services for which HCPCS modifier GY may be appropriate include: routine physicals, laboratory tests in absence of signs or symptoms and hearing aids
  • Both Medicare beneficiaries and providers have certain rights and protections related to financial liability under the Fee-for-Service (FFS) Medicare and the Medicare Advantage (MA) Programs. These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers.
  • The revised Advanced Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131 (3/2011) may be used to provide voluntary notification of financial liability. Thus, this version of the ABN should eliminate any widespread need for the Notice of Exclusion from Medicare Benefits (NEMB) in voluntary notification situations.
  • The CMS ABN form is available at CMS website

Examples of Incorrect Submission
Analysis of submitted claims indicates that HCPCS modifier GY is sometimes submitted incorrectly. The following examples illustrate incorrect submission of this modifier.

  • Ambulance Transports: HCPCS modifier GY is being submitted on ambulance claims in error when the ambulance transport meets Medicare guidelines for coverage (e.g., the patient could not have traveled by any other means without his/her health being endangered)
  • Laboratory Tests: HCPCS modifier GY is sometimes submitted when HCPCS GA (advance notice has been given to the beneficiary) is more appropriate. Examples include CPT codes 61630, 61635, and 61640 through 61642. These CPT codes are designated as "status N" codes in the CMS Medicare Physician Fee Schedule Database (MPFSDB), which means that the procedures are subject to limitation of liability. In these situations, it is appropriate to ask the patient to sign an ABN.

References

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