Modifier GY: Description, Examples & Usage Guidelines

Not all care services are covered by Medicare. But that does not mean that you should not inform them about the rendered procedure by submitting a medical claim. 

Of course, you should! But the question is, if a service is not covered, then will it not result in a claim denial? It will, and it should be! However, to make things simple and to generate an immediate clean denial, some specific G modifiers are available.

This guide will exclusively cover everything you need to know about the GY modifier. We will not only explain what it means, but also share some use cases and accurate usage guidelines. 

So, without further ado, let’s get started!

What is a GY Modifier?

Modifier GY is a Medicare-specific code that is appended to statutorily excluded (non-covered) services or procedures. It indicates to the payer that you are aware that the service is non-reimbursable. As a result, you are expecting a clean denial for the medical claim, so that the financial responsibility can shift to the patient. 

Appropriate Use Cases for Modifier GY

The following are a few real-world clinical scenarios offering a glimpse into the proper application of the GY modifier:

Cosmetic or Non-Covered Surgery

Picture a 25-year-old female patient who requested the dermatologist to remove moles (benign skin lesions) for cosmetic reasons. That is, she does not experience any symptoms, such as bleeding or pain.

Medicare does not reimburse for services that are rendered primarily for cosmetic reasons. Thus, the excision of the moles will fall under non-covered services since it was not medically necessary.

Here, the dermatologist will report CPT code 11400 with GY modifier to receive a clean denial from Medicare.

Experimental Diagnostic Test (Genetic)

Suppose a 68-year-old male patient has a strong history of colon cancer. His brother and father were diagnosed in their early 50s. However, his own colonoscopy came back normal 4 years ago. Besides, he is currently asymptomatic. That is, he has no pain, bleeding, or any changes in bowel habits.

His primary care physician recommends a multi-gene panel blood test to assess the future risks of getting colon cancer beyond standard screening. 

This diagnostic test is considered investigational for asymptomatic patients by CMS. Simply put, it is statutorily excluded from Medicare coverage.

Therefore, CPT code 81401 must be reported with the GY modifier to trigger an immediate denial.

Routine Foot Care without Systemic Condition

Imagine a 36-year-old healthy female patient who comes to the clinic for routine toenail cutting and shaping. However, the patient does not have any qualifying systemic condition like neuropathy, peripheral vascular disease, or diabetes. As a result, the procedure is considered medically unnecessary.

Here, the physician will append the GY modifier to HCPCS code G0127 to trigger a denial.

Accurate Usage Guidelines for Modifier GY

Discussed below are the guidelines to ensure accurate usage of modifier GY:

Understand When You Should Append the GY Modifier

Here’s when you append modifier GY:

For Statutorily Excluded Services

Report it if the performed procedure is statutorily excluded from Medicare coverage. Common examples include routine foot care for a patient without a qualifying systemic illness, cosmetic surgery, personal comfort items, and custodial care. 

For Experimental/Investigational Services

You should use the GY modifier for procedures, diagnostic tests, and other services that are experimental or investigational as identified by Medicare. The federal program typically does so by issuing a National Coverage Determination (NCD) or a Local Coverage Determination (LCD).

For Non-Covered Benefit Category

In case a certain service, such as a specific dental service or a wellness program, does not fall into a Medicare benefit category, always report it with modifier GY.

Know When NOT to Use the GY Modifier

If you want to do it right, then understand when not to use the modifier GY. Discussed below are some instances where you should never report it:

Expected Denial Due to Lack of Medical Necessity

There may be circumstances when you expect a claim denial because you believe the patient’s condition does not meet the criteria set forth by Medicare. For example, too many physical therapy visits that were not medically necessary. Here, the GY modifier is not applicable. 

The correct approach in these situations is to report the service with one of the following modifiers:

• Modifier GA: Waiver of liability statement issued with a signed advanced beneficiary notice (ABN) on the file.
• Modifier GZ: Item or service expected to be denied as not reasonable and necessary, no ABN issued to the patient.

Preventive Service Outside Scope or Frequency Limit

What happens when covered preventive services, such as G0444 for depression screening, exceed the allowed billable limit or are out of scope? Do not append the GY modifier since it is a covered service. Instead, go for modifier GZ if an ABN is not on the file.

Global Period Issues

You should not use modifier GY to bypass billing rules related to global periods of services.

Non-Medicare Payers

Remember that GY is a Medicare-specific modifier. Thus, you should avoid reporting it on private payer claims unless the payer explicitly states to append it.

Fulfill Documentation Requirements

We know that the GY modifier highlights that the rendered procedure is statutorily excluded. Therefore, the focus of documentation here will shift from demonstrating medical necessity to confirming the patient’s consent for the non-covered service. Simply put, you should include the following:

• Explain which procedure you performed.
• Describe why the service is non-covered.
• Explicitly mention that the patient knows that Medicare will not reimburse for the service. Besides, it is their financial responsibility to pay for it.
• No need to obtain an ABN. In case you have already acquired it, you should report modifier GX as well with GY.

Final Thoughts

With the GY modifier, reporting for statutorily excluded services becomes simpler. The reason is that it ensures you steer clear of audits. But, how? Billing non-covered services without this modifier may seem as if you are trying to receive unfair reimbursement through fraudulent activities.

However, modifier GY triggers clean denials on claims without jeopardizing your practice’s reputation and prevents you from getting penalized. Hopefully, this guide will help you use it appropriately. However, if you still struggle, consider partnering with a professional medical billing and coding company, like NeuraBill.

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