CODING UPDATE: New Hospital Modifiers Introduced

Modifiers -GY and -GZ appeared for the first time in the list of approved hospital outpatient HCPCS Level II modifiers in a program memorandum (PM) to Medicare intermediaries on Jan. 3, 2003. Titled "2003 Update to the Hospital OPPS," the PM incorporated 33 pages of changes for hospitals effective Jan. 1, 2003.
It is not surprising modifiers -GY and -GZ are now applicable for hospitals since they closely relate to the process for modifier -GA "waiver of liability." The following are the definitions of the new modifiers:
-GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit
-GZ Item or service expected to be denied as not reasonable and necessary
Applying these modifiers correctly requires a thorough knowledge of Medicare coverage guidelines, most specifically, statutory exclusions and local medical review policies.
Statutory Exclusions
The statutory exclusion lists those services that are excluded from Medicare benefits. When such services are provided to a beneficiary, he or she is liable for full payment.
The following is a list of statutory exclusions, which fall under personal comfort items.
Personal comfort items This is only a general summary of exclusions from the full menu of Medicare benefits. The official Medicare program provisions are contained in relevant laws, regulations, and rulings.
This list includes the following:
- routine physicals and most tests for screening
- most shots (vaccinations)
- routine eye care, eyeglasses, and examinations
- hearing aids and hearing examinations
- cosmetic surgery
- most outpatient prescription drugs
- dental care and dentures (in most cases)
- orthopedic shoes and foot supports (orthotics)
- routine foot care and flat-foot care
- healthcare received outside of the United States
- services by immediate relatives
- services required as a result of war
- services under a physician's private contract
- services paid for by a governmental entity that is not Medicare
- services for which the patient has no legal obligation to pay
- home health services furnished under a plan of care, if the agency does not submit the claim
- items and services excluded under the Assisted Suicide Funding Restriction Act of 1997
- items or services furnished in a competitive acquisition area by any entity that does not have a contract with the Department of Health and Human Services (except in a case of urgent need)
- physicians' services performed by a physician assistant, midwife, psychologist, or nurse anesthetist, when furnished to an inpatient, unless they are furnished under arrangements by the hospital
- items and services furnished to an individual who is a resident of a skilled nursing facility or part of a facility that includes a skilled nursing facility, unless they are furnished under arrangements by the skilled nursing facility
- services of an assistant at surgery without prior approval from the peer-review organization
- outpatient occupational and physical therapy services furnished [...]

- Published on 2003-03-01