Definition:
• If the service provided is statutorily excluded from the Medicare Program, the claim will deny whether or not the modifier is present on the claim.
Example:
Patient transport is for a non-covered condition that does not meet the definition of any Medicare benefit. The provider is expecting a denial.
Appropriate Usage:
• Services provided under statutory exclusion from the Medicare Program, the claim would deny whether or not the modifier is present on the claim
• It is not necessary to provide the patient with an ABN for these situations.
• Situations excluded based on a section of the Social Security Act.
• Modifier GY will cause the claim to deny with the patient liable for the charges.
Inappropriate Usage:
• Do not use on bundled procedures.
• Do not use on add-on codes.
Are chiropractors required to submit therapy codes with both the GP and the GY HCPCS modifiers?
Answer:
Therapy services provided by a chiropractor, although non-covered, must be submitted according to therapy guidelines. Therefore, please be sure to include one of the therapy modifiers defined below. Therapy services submitted without the appropriate therapy modifier, including services submitted with HCPCS modifier GY, will be rejected as unprocessable.
HCPCS modifier GN – Services delivered under an outpatient speech-language pathology plan of care
HCPCS modifier GO – Services delivered under an outpatient occupational therapy plan of care
HCPCS modifier GP – Services delivered under an outpatient physical therapy plan of care
A list of codes that require therapy modifiers is available on the CMS website external link .
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