Basics of GY and GZ modifier

The Center for Medicare and Medicaid Services (CMS) created two modifiers (GY and GZ modifier) that allows you to distinguish between services that are statutorily not covered or otherwise not a Medicare benefit because Medicare does not consider them “reasonable and necessary”. G modifiers are a specific set of modifiers used to indicate that a service or item is not covered by Medicare. The most common modifiers include GA, GX, GY, and GZ.

Read also: Coding guide for Hospice GV and GW Modifer

Definitions of the GZ and GY Modifier

GY – Item or service statutorily excluded or does not meet the definition of any Medicare benefit.

GZ – Item or service expected to be denied as not reasonable and necessary.

GY  Modifier is added to claims in which the item or service is statutorily excluded, does not meet the definition of any Medicare benefit.

“Statutorily Excluded” means Medicare benefit only applies to items or services that are legally defined as essential services. Certain services and items, such as hearing aids, corrective dental items like braces, and temporary prosthetic devices, do not meet the definition of services and goods included in the Medicare benefit.

GY modifier may also be used when the patient’s secondary insurance depends on a Medicare denial. Most claims submitted with a GY modifier will be denied automatically by the carrier or a fiscal intermediary. With these cases, a beneficiary will be liable for the charges. And that’s an important statement for you to know.

Medicare for secondary payer purpose, the claim should be submitted with GY HCPCS modifier. This way the claim may be processed faster than it would be without GY HCPCS modifier. Advanced Beneficiary Notices (ABNs) are not acceptable for statutory exclusions.

Read also: Medical billing Terminology and glossary

Appropriate use of GY modifier

• Append when services are provided under statutory exclusion from Medicare Program
• It is not necessary to provide patient with an ABN for these situations
• Situations excluded based on a section of the Social Security Act
• Append to cause claim to deny with patient liable for charges *

The GY modifier is similar to the GZ modifier in that it is used to specify that the supply or service is not supported by any definition of Medicare accepted policies. The difference between the GY and the GZ modifier is the issuing of an ABN.

Appropriate Use of GY modifier

• Append when services are provided under statutory exclusion from Medicare Program
• It is not necessary to provide patient with an ABN for these situations
• Situations excluded based on a section of the Social Security Act
• Append to cause claim to deny with patient liable for charges

The GZ modifier identifies that

1) an item or service is expected to be denied as not reasonable and necessary, and

2) no advance notice of non-coverage was supplied to the member.

If you bill us for services using the GZ modifier, the claim will go to provider liability and you may not bill the member.

The GZ modifier indicates that an Advance Beneficiary Notice (ABN) was not issued to the beneficiary and signifies that the provider expects denial due to a lack of medical necessity based on an informed knowledge of Medicare policy.

This modifier is an informational modifier only. An informational modifier is a medical coding modifier not classified as a payment modifier. Another name for informational modifiers is “statistical modifiers.” Payment modifiers are modifiers that have an impact on payment of the claim. An example of this is adding the 50 CPT modifier for bilateral services. When the 50 CPT modifier is added, the code billed gets reimbursed at 150 percent of the Medicare allowable amount.

Appropriate use of GZ Modifier

• The GZ modifier is used when you expect Medicare to deny the service and you do not have an ABN form signed.
• Use this modifier when you forgot the ABN.
• Expect an audit if you use this modifier Q6 Modifier
• Services provided by a Locum Tenens physician
• Use this modifier when you have another doctor filling in for you.
• A Locum Tenens doctor can fill in for 60 days.