Is the GY modifier necessary on all drugs that are considered self-administered when administered in an outpatient setting; emergency department, observation and facility-based clinics? What is the appropriate use of the GY modifier?
It is not necessary to place the GY modifier on drugs considered self-administered. Revenue code 637 – Self-Administrable Drugs may be assigned to all drugs in this category.
Information regarding the use of the GY modifier (Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit) may be found in the Medicare Claims Processing Manual, CMS Publication 100-04, Chapter 1, §60 – Provider Billing of Non-covered Charges on Institutional Claims:
“60.1.2 – Billing Services Excluded by Statute
The billing instructions in this subsection apply to payment condition 1.
Medicare will not pay for services excluded by statute, meaning that Title XVIII of the SSA either:
• does not describe the items and services in question as all or part of a covered Medicare benefit, or
• describes, but excludes, such items and services from coverage.
Examples of such services are given to beneficiaries in the “Medicare and You” handbook. These services can be billed to Medicare as non-covered on institutional claims.
Items and services excluded by statute cannot necessarily be recognized in specific procedure or diagnosis codes. For example, in some cases, a given code may be covered as part of a given Medicare benefit, but under other cases, when no benefit exists, the same code would not be covered by Medicare. For claims submitted to Medicare contractors, these services that are not Medicare benefits may be:
(A) Not submitted to Medicare at all (see A, immediately below),
(B) Submitted as non-covered line items, or
(C) Submitted on entirely non-covered claims.
A. Medicare does not require procedures excluded by statute to be billed on institutional claims UNLESS:
(1) Established Medicare policy requires either all services in a certain period, covered or non-covered, be billed together so that all such services can be bundled for payment consideration (i.e., procedures provided on the same day to beneficiaries under OPPS), or
(2) Billing is required for reasons other than payment (i.e., when utilization days must be charged in inpatient settings where the benefit itself is limited in duration, such as the 100 day limit of Part A payment for a SNF stay); or
(3) A beneficiary requests Medicare be billed so that the item or service in question will be reviewed by Medicare to make an official payment determination (more on demand billing in §60.3 in this chapter).
B. To submit statutory exclusions as non-covered line items on claims with other covered services, modifiers like –GY can be used on noncovered line items.
C. To submit statutory exclusions on entirely non-covered claims, use condition code 21, a claim-level code, signifying all charges that are submitted on that claim are non-covered charges.”