2025 HCPCS code GY
Modifier GY is appended to a code to indicate that a service or item is statutorily excluded from Medicare coverage or doesn't meet the definition of a Medicare benefit, or for non-Medicare insurers, is not a contract benefit.
No other modifiers are typically used with GY.
Medical necessity is not a relevant factor when modifier GY is used since the service is inherently excluded from Medicare coverage by statute or is not defined as a Medicare benefit.
In simple words: Modifier GY means Medicare isn't required to cover this service, and you'll likely have to pay for it yourself.
The HCPCS modifier GY is used to identify items or services that are statutorily excluded by Medicare or do not fall under any Medicare benefit category.For non-Medicare insurers, it indicates that the service is not a contracted benefit.It signals that the provider anticipates the claim will be denied by Medicare and that the patient is likely responsible for payment. An Advance Beneficiary Notice (ABN) is typically not required when using this modifier.
Example 1: A patient receives acupuncture treatment, which is generally not covered by Medicare.The GY modifier is appended to the acupuncture CPT code., A patient undergoes cosmetic surgery purely for aesthetic purposes. This procedure is not a Medicare benefit and would be billed with the GY modifier., A Medicare patient receives routine dental care (e.g., cleaning, filling). Since most dental care is excluded from Medicare coverage, the dentist would use modifier GY.
The submitted claim should clearly document the specific item or service provided and include the GY modifier.The reason for the statutory exclusion or lack of Medicare benefit should be clear.
** For certain commercial payers, GY can also indicate that the service is not a contracted benefit.
- Specialties:Various specialties might use GY depending on the service. For example, it could apply to acupuncture by an acupuncturist, cosmetic surgery by a plastic surgeon, or non-covered dental procedures by a dentist.
- Place of Service:Applicable in various places of service depending on the procedure/service provided (e.g., "Office" for cosmetic procedures, "Independent Clinic" for acupuncture, "Office" for non-covered dental services).