Durable Medical Equipment - Proper Use of GY, GA and GZ Modifiers
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Durable Medical Equipment - Proper Use of GY, GA and GZ Modifiers

The following provides the proper use of GY, GA and GZ modifiers.

Noncovered Items - GY Modifier

The GY modifier was established to describe situations in which an item with a specific HCPCS code is non-covered.

GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit

It is important to distinguish situations in which an item is denied because it is statutorily excluded or does not meet the definition of any Medicare benefit from those situations in which an item is denied because it is not reasonable and necessary.  Some examples of statutorily excluded items or situation include, but are not limited to:

  • Hearing aids
  • Eyeglasses or contact lenses, except those provided following cataract removal or other cause of aphakia
  • Durable medical equipment and related accessories and supplies provided to patients in nursing facilities
  • Dental items
  • Personal comfort items
  • Orthopedic shoes or shoe inserts, other than those covered under the therapeutic shoes for persons with diabetes benefit or those that are attached to a covered leg brace

Some examples of items or situations that do not meet the definition of a Medicare benefit include, but are not limited to:

  • Parenteral or enteral nutrients that are used to treat a temporary (rather than permanent) condition
  • Enteral nutrients that are administered orally Infusion drugs that are not administered through a durable infusion pump
  • Surgical dressings that are used to cleanse a wound, clean intact skin, or provide protection to intact skin
  •  Immunosuppressive drugs used for conditions other than following organ transplants
  • Durable items that are not primarily designed to serve a medical purpose, e.g., exercise equipment

Use of the GY modifier is usually limited to situations in which there is a specific HCPCS code to describe the item.  If there is no specific HCPCS code to describe the item, then code A9270 (Noncovered item or service) is usually used.  The GY modifier should generally not be used with a "miscellaneous" or "not otherwise classified" codes. e.g., E1399.  The GY modifier is not needed with code A9270.  Code A9270 must not be used in situations in which an item is expected to be denied as not reasonable and necessary.

An Advance Beneficiary Notice (ABN) is not required for items that are statutorily excluded from coverage or that do not meet the definition of any Medicare benefit category since the DME MAC does not make limitation of liability determinations for these types of denials.

Not Medically Necessary Items

GA/GZ Modifiers - The GZ modifier was established to describe certain situations in which an item or service is expected to be denied as not medically necessary and an ABN was not obtained or properly obtained.  The GA modifier is used in other situations in which an item or service is expected to be denied as not medically necessary and an Advance Beneficiary Notices has been properly executed.

GZ - Item or service expected to be denied as not reasonable and necessary (Used when an Advance Beneficiary Notice is not on file)

GA - Waiver of liability statement on file (Used when an item or service is expected to be denied as not reasonable and necessary and an Advance Beneficiary Notice is on file).

It is important to distinguish situations in which an item is denied because it is not reasonable and necessary from those situations in which an item is denied because it is statutorily excluded or does not meet the definition of any Medicare benefit.  Some examples of items or situations that are medically necessity denial include, but are not limited to:

  • Items which are not ordered by a physician or qualified nurse practitioner, clinical nurse specialist, or physician assistant
  • Items which do not meet medical necessity coverage criteria or frequency guidelines specified in national coverage or local coverage determination (LCD)
  • Items which are the same as or similar to covered items that the beneficiary is already using
  • Items whose safety and effectiveness in the home setting has not been established
  • Experimental or investigational items

A GZ or GA modifier can be used on either a specific or a miscellaneous HCPCS code.  It would never be correct to place any combination of GY, GZ or GA modifiers on the same claim line.  If these modifiers are used on the same claim line, it will be rejected or denied for invalid coding.

Important Note:  The DME MAC and DME PSC monitor the utilization and proper usage of modifiers.  Suppliers may ensure that modifiers are only used when appropriate and that all required supporting documentation is available upon request.  This is especially true for usage of the GY modifier.

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