2025 HCPCS code EY

No physician or other licensed health care provider order for this item or service.

The EY modifier should be appended to each line item on the claim for which there is no physician or licensed healthcare provider order.Failure to include the EY modifier may result in the claim being returned as unprocessable.

Other modifiers may be applicable in addition to the EY modifier, depending on the specific circumstances of the service/item provided.

While the EY modifier signals the lack of a physician's order, which typically affects medical necessity for Medicare, the underlying need for the item or service itself might still be medically necessary. It's crucial to distinguish between the requirement for an order (administrative) and the clinical need (medical necessity).

The supplier is responsible for appending the modifier and understanding the COB implications.

In simple words: This code is used when a medical supply or service is provided without a doctor's order. It lets the insurance company know that the provider is expecting the claim to be denied because Medicare usually requires a doctor's order for these things.

This modifier is used to indicate that a service or item was provided without a physician's or other licensed healthcare provider's order.For Coordination of Benefit (COB) purposes, suppliers use the modifier EY on each line item of the claim and report their own name and National Provider Identifier (NPI) as the ordering/referring provider. This is done to obtain a Medicare denial under COB guidelines when a patient has more than one health insurance plan.If a provider has an order for some, but not all, of the items/services furnished to the Medicare beneficiary, the provider must submit a separate claim for the items dispensed without the treating physician’s order.

Example 1: A patient receives durable medical equipment (DME) from a supplier without a physician's order. The supplier appends the EY modifier to the DME HCPCS code on the claim., A patient receives orthotic supplies without a prescription or order from a licensed healthcare provider. The supplier bills with the EY modifier, expecting denial for secondary insurance billing., A patient with Medicare and a secondary insurance requires a wheelchair. The supplier provides the wheelchair without the required physician's order and uses the EY modifier to trigger a denial from Medicare, allowing the secondary insurance to process the claim as primary.

Documentation should support the medical necessity of the item or service, even though it was provided without a physician’s order. The reason for the absence of an order should also be documented.

** The EY modifier is primarily for informational purposes, informing the payer that the service or item lacks a physician order.It's important to consult specific payer policies for COB guidelines and documentation requirements.As of December 1st, 2024, this information reflects the current understanding of the EY modifier usage.

  • Payment Status: Denied
  • Specialties:Durable Medical Equipment (DME) suppliers, Orthotic and Prosthetic (O&P) suppliers, and other healthcare providers who dispense supplies or services.
  • Place of Service:Applicable to various places of service where DME or other supplies/services are provided, such as the patient's home, a physician's office, or an outpatient facility.
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