Ophthalmology and Optometry Coding Alert

Question: A doctor recently told me that appending modifier GY to the refraction code would guarantee payment by a secondary insurer when Medicare denies it. Is this true?

Illinois Subscriber

Answer: Modifier GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) does not guarantee payment from a patient's secondary insurance -- but that doesn't mean you shouldn't append it.

One of the few constant and heavily documented truths in coding is that Medicare will never pay for refractions (92015, Determination of refractive state). Some non-Medicare insurers will pay for the service, however.

A patient who has supplemental insurance in addition to Medicare may need to show the secondary insurer  that Medicare denied the refraction claim in order to be reimbursed for it.

In those cases, you can submit a claim of 92015-GY to Medicare. This notifies Medicare that you're aware that the service isn't covered, but you're billing simply to obtain a denial for submission to a secondary payer or billing the service at the insistence of the patient. Medicare will automatically deny the claim, and the explanation of benefits will state that the patient is liable for the charge.

Best bet: Have patients pay for the service in advance unless your records show that the secondary insurance paid for a previous refraction.