Modifier – GY and Refractions

It is well known in the ophthalmic world that Medicare does not cover refractions. They are noncovered by statute. Statutory exclusions from the Medicare program do not require an Advance Beneficiary Notice (ABN). They also do not require the physician to file a claim on behalf of the beneficiary, unless the beneficiary specifically requests one. Many patients desire a Medicare denial to submit to a secondary insurer or want validation from Medicare that it is a noncovered service with patient responsibility. Claims containing statutory exclusions filed on behalf of the beneficiary should be appended with the modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit.)

Many practices do not utilize this modifier with refractions. With or without the modifier, the claim is denied. Recently, NHIC, the Medicare carrier in California, published a notice that one of the top errors in claim submission is the submission of procedure code 92015. They state, “Non-covered services without the GY modifier will be considered a claim submission error and may result in a provider review by the CERT contractor. To avoid unnecessary denials and reviews; use the GY modifier when appropriate!”

We expect to see this type of tracking by other Medicare carriers, so it may be worthwhile to append the modifier to secure the appropriate denial code on explanations of benefits.