Can a service with the GY HCPCS modifier be appealed?

Healthcare Common Procedure Coding System (HCPCS) modifiers have very distinct definitions and uses within Medicare. There are times when a provider should use the GY HCPCS modifier to indicate that the 'item or service statutorily excluded or does not meet the definition of any Medicare benefit'. The services are specifically excluded based on a section of the Social Security Act. There are no Advance Beneficiary Notice (ABN) requirements for statutory exclusions.

When the GY HCPCS modifier is used, it will cause the claim to deny with the patient liable for the charges. These denials can be appealed by either the provider/supplier or the beneficiary. If Medicare pays the claim, the GY HCPCS modifier is irrelevant. The provider cannot collect amounts above the co-insurance and deductible or the limiting charge amount.

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Provider Contact Center: 888-355-9165

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TTY: 877-715-6397

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