Coding and Reimbursement
Using the New -GY Modifier
It helps to eliminate erroneous Medicare payments and prevent patient confusion.

BY SUZANNE L. CORCORAN, COE

 As you know, Medicare only pays for procedures that are necessary for the diagnosis or treatment of illness or injury. That means that Medicare doesn't cover refractive surgery (except when iatrogenic astigmatism is involved), routine eye exams, eyeglasses (except post-cataract glasses), cosmetic surgery, or services to family members.

However, in some situations, such as when a supplemental insurance carrier needs a denial from Medicare in order to process its claim, your office may need to file a claim for one of these services. In those cases, you can use the new modifier -GY to generate a denial.

Q: Why did Medicare add the new modifier? Before 2002, the only option when seeking a denial was to use the
-GA modifier. Modifier -GA indicates:

• that you expect a denial for the service because it's not medically necessary
• that the patient has been informed of this fact in advance
• that a signed advance beneficiary notice (ABN) has been completed.

However, Medicare's computers often make payment even when modifier -GA is used on the claim, resulting in many unhappy and confused patients. Payments are sometimes made because modifier -GA means the provider "believes the service may not be medically necessary," which is not the same as a clear, unqualified statement that this claim should not be paid. For that reason, Medicare has no computer edits that automatically deny -GA claims.

To minimize confusion, Medicare added modifier -GY at the beginning of 2002. This modifier is intended to be used with claims that you are sure should be denied because the service isn't a Medicare benefit, or because Medicare law specifically excludes it. In contrast to modifier -GA, the new modifier is defined as statutorily noncovered, so Medicare's computers will automatically deny the claim. Also, it automatically generates a notice to the beneficiary that he or she is liable for all charges, either personally or through other insurance.

Q: When is it appropriate to use modifier -GY? Here are two examples of situations in which you might use the new modifier:

Refractive exam. Some patients have other insurance coverage that may pay when Medicare does not, and the supplemental insurance carrier may need a denial from Medicare in order to process its claim. One example is the patient who only wants new eyeglasses and has no eye disease or other complaint. Submit the claim to Medicare with modifier -GY and a diagnosis indicating routine eye care (e.g., 367.xx Disorders of refraction, or V72.0 Routine examination of eyes and vision).

Refractive procedure. Refractive surgery isn't covered when performed as a substitute for eyeglasses or contact lenses to treat refractive error (unless correction of iatrogenic astigmatism is involved). Nor is surgical correction of noniatrogenic astigmatism by corneal or limbal relaxing incisions, a common elective procedure performed at the time of cataract surgery.

If you need to generate a denial so the patient can see that Medicare won't pay, use CPT code 66999 (to describe an unlisted procedure for the anterior segment of the eye), with modifiers -GY and -51 (indicating a multiple surgery). Astigmatism would be the primary diagnosis associated with this code.

Q: Do I need to get a signed ABN as well? No, advance beneficiary notices are not required for statutory exclusions. However, an ABN can be an effective tool to notify patients of their financial obligation, so you may wish to have the patient sign one anyway. Many practices also develop their own forms to notify patients about financial responsibility for cosmetic, routine or refractive procedures.

Suzanne L. Corcoran, COE, is vice president of Corcoran Consulting Group. She can be reached at (800)399-6565 or via e-mail at scorcoran@corcoranccg.com.