GY Modifier

GY Modifier (2022) Description, Uses, Guidelines & Examples

Modifier GY appends to services when the physician performs an item or service statutorily excluded, does not meet the standard definition of any Medicare and non-Medicare insurer, and is non-covered in benefit.  

GY Modifier Description

GY Modifier appends with the service when the physician performs services or items that are statutorily excluded and do not meet the criteria of Medicare guidelines for reimbursement.  

The two modifiers, GZ and GY, are recognized by the CMS (Center for Medicare & Medicaid Services) to differentiate between non-covered or not medically necessary or reasonable service. These modifiers report for reimbursement and are statutorily excluded or otherwise not a Medicare benefit. This modifier requires indicated at the time of submission. 

The statutorily excluded deals with the services not covered by the Medicare benefit plan according to law, and “Statutory” refers to written law. Medicare may not reimburse all the services or costs when a bill by the physician. This service will never be paid under any circumstances, even documentation supporting the services or not. 

Medically necessary services are when the physician performs health care services or supplies aids to diagnose the patient’s condition, injury, illness, symptoms, or disease and to the rules and regulations. 

If the service does not meet the standards of CMS guidelines and criteria, it may be inappropriate or not reasonable to perform. Therefore, this service will be statutorily excluded from the Medicare program and may deny by the insurance whether or not modifier GY appends to this service. 

If modifier GY attaches to the claim or service will be atomically denied by the insurance. The beneficiary may be responsible for these charges and pay for these services through a secondary payer or insurance. 

For Instance, the physician sees a patient with plastic surgery on the nose, which is not medically necessary or needed, and may deny by Medicare insurance. If modifier GY appends to this service, the claim will automatically reject by Medicare, bills to the patient’s secondary insurance, or the patient has no.

It makes the process smoother than submitting the claim without modifier GY. Advanced Beneficiary Notices (ABNs) are also not applicable for statutory exclusions.

The ABN is inappropriate for the following services: “statutory exclusions” or “categorical exclusions” and technical denials. 

modifier gy

What Is GY Modifier?

Modifier GY attaches to services or items which are non-covered by the insurance, and the beneficiary may be responsible for charges.

When To Use GY Modifier

Modifier GY appends with the services when the physician performs statutory exclusion from the Medicare program, and the claim may automatically deny whether Modifier GY is attached or not.  

Modifier GY does not require ABN from the patient for these situations.

Situations excluded applying to these services by the section of the socials security act.

The patient does liable for the services, and modifier GY may automatically deny the items or service by the insurance without manual review. 

GY Modifier Guidelines

Modifier GY is inapplicable to use with bundled procedures, and it is appropriate to report with unbundle modifier or may write off if the modifier is not allowed.

Modifier GY is inapplicable to use with add-on codes mentioned in the AMA CPT code book.

Modifier GY is irrelevant to add with the CPT code when Medicare pays the claim. 

Modifier GY applies for the services such as laboratory or routine physical tests in the absence of indication, air conditioners, services to a family member, and services that may perform in a foreign country.  

Modifier GY applies for the services when a physician performs the surgery they do not legally authorize. 

Modifier GA, GY, and GZ are applicable for the service when bills to DMERCs. The main difference between modifier GY and GZ is when the physician knows that the service is non-covered by Medicare (Modifier GY) and the possibility of service denied by Medicare.

Modifier GZ requires Advance Beneficiary Notification (ABN) signs by the patient for not adequate and necessary service. 

The following are the services that are not medically necessary and not reasonable when bills to Medicare. Therefore, it is appropriate to report with modifier GY:

The hospital utilizes expensive services for the patient’s conditions while a lower-cost setting performs these services, such as a nursing home or the patient’s home.

The Patent stays Longer than Medicare’s designated time and exceeds the duration limit.

The medically unnecessary services exceed the level of evaluation and management service time. Therefore, for Instance, The appropriate CPT code will be 99213, but it reaches 99214 for inadequate services. 

The facilities perform unnecessary therapy or diagnostic procedures to diagnose a specific patient condition. 

The patient has no signs and symptoms to perform such examinations, and Unrelated screening tests may serve for the condition. 

The transcendental meditation service provides to the patient is unnecessary and not reasonable.

The Facility assists the patient in causing or assisting the death.

Modifier GY and GZ must apply with a specific HCPCS code if it is available for the service or item. Otherwise, NOC code may apply to these services with GY and GZ modifiers when no specific code is available.

The following are NOC codes available for the service that are statutorily non-covered and do not meet the definition of medicare benefit. Therefore, the service is medically unnecessary or not appropriate modifier GY and GZ:

HCPCS A9160 bills for the service when the podiatrist performs the service.

HCPCS A9170 bills when the chiropractor performs the service.

HCPCS A9190 bills for the service when performed for personal comfort and is not covered by Medicare. 

HCPCS A99270 bills for the service when the suppliers, practitioners, and physicians perform the service non-covered or statutory exclusion. This code is effective from January 1, 2002, for services that do not meet the standards of Medicare benefits. There is no specific procedure available to code for the services or items. 

Suppose modifier GA and GY appends with the service when the suppliers, practitioners, and physicians for the same item or service. It may deny by the insurance as invalid modifiers and unable to process these claims.

GY Modifier Examples

The following are the example modifier Gy appends with the services. 

Example 1

58 y/o male with a PMH of HTN, HLD, and hypothyroidism presents to the hospital outpatient setting because of a headache and high blood pressure before arrival. The patient lays in bed at 10 pm and begins having a gradual onset pulsating frontal and occipital headache. 

He reports that the pain was very severe. His headaches are usually associated with HTN. The blood pressure shows a value of 210/100 and denies associated dizziness, chest pain, shortness of breath, motor weakness, numbness/tingling, abdominal pain, nausea/vomiting. 

The physician ordered CT, MRI, and EKG diagnostic tests. EKG was independently interpreted and reviewed by the doctor. 

The patient presents to the hospital with a headache. At the same time, the Facility performs unrelated screening and diagnostic tests such as CT and MRI of the chest, which may not require for the patient’s condition.

The patient asks for these tests, and ABN does not appropriate for these services. Therefore, it is suitable to report with modifier GY for patient liability. 

Example 2

A 51-year-old-female presents to the emergency with syncope. The patient applies a nicotine patch earlier. The patient had a brief episode of feeling hot, numbness, and tingliness in her b/l hands, “gas discomfort” in her stomach, and headache. When she tried to get up, she lost consciousness(witnessed by her partner, who I spoke to for more history). 

Partner states she was only out for a few seconds before perking up to routine. Pt states she has had episodes like this in the past but several years ago. No known cardiac history. Physicians plan to order CBC, CMP, mg, phos, trop, EKG, Tylenol, Pepcid, and Zofran. CMP repeated twice in one day and expected to deny by the insurance. 

The patient asked for a PT session in the hospital which was unnecessary for the patient’s condition. The hospital provides this service to the patient. The ABN is inappropriate to issue for this service. The secondary patient insurance may cover this service. Modifier GY appends to the service for efficient claim submission to secondary insurance. 

Example 3

36-year-old male presents to the emergency department with PMH HTN, HLD, Afib (on eliquis), Mitral valve replacement, and gout; presenting to the Office today for dark blood stools for two days. He states that he started diarrhea yesterday and had 4 BM in the past two days.

 The patient denies nausea, vomiting, CP, SOB, dizziness, fevers, chills, and took eliquis this morning. The physician also notes worsening bilateral lower extremity edema, for which he takes Lasix. In addition, he took Indomethacin for four days for a presumed gout flare. 

The colonoscopy was done three years ago and found benign polyp but otherwise WNL. Physician plan to admit and Plan Labs, EKG, CT abdomen, and Pelvis, and prescribed Medicine. 

The Facility performs an inappropriate exam for the patient, such as CT and MRI of the brain, which may not require for the Patients condition. ABN does not need CT and MRI of the brain and modifier GY appropriate to report with these services. 

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