Modifier EY

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

Correct Use

  • Append to claim line when specified requirements for an order are not met
    • This informs Noridian that you do not have a physician's order for item
  • Items submitted with this modifier must be on a separate claim from those items not requiring this modifier

Denies not reasonable and necessary

  • ABN recommended to protect supplier from liability
  • Exception: Items that require an order by statute or detailed written order prior to delivery (WOPD)

Modifier Requirements Due to Lack of Physicians Order - Modifier EY and GA

What is the proper submission of modifiers EY and GA when a denial is anticipated due to the lack of a prescription?

  • All durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items require a prescription (physician's order). All DMEPOS items require a standard written order prior to billing. Please refer to the Standard Documentation Requirements on the CMS website for order requirements.
  • EY - Please remember that if you submit a claim to Medicare and specified requirements for an order are not met, you must append modifier EY (no physician or other licensed health care provider order for this item or service) to the claim line. This informs the Durable Medical Equipment, Medicare Administrative Contractor (DMEMAC) that you do not have a physician's order for the item. Additionally, items submitted with the EY modifier must be on a separate claim from those items not requiring an EY modifier.
  • GA - When lack of an order is expected to result in a medical necessity denial (ANSI 50 –these are non-covered services because this is not deemed a 'medical necessity' by the payer"), you must execute an Advance Beneficiary Notice of Noncoverage (ABN) if you intend to protect your company from financial liability. If you have properly executed an ABN, you must append modifier GA (waiver of liability statement issued as required by payer policy, individual case) to the claim line in addition to modifier EY.
    • When the lack of a physician's order is expected to result in a statutory denial, an ABN is not required. If you correctly submit the claim with modifier EY appended to the claim line, the claim will process and deny with ANSI 96 (non-covered charge(s)). Neither modifier GY (item or service statutorily excluded, does not meet the definition of any Medicare benefit) nor modifier GA is required when an item is expected to deny based on a statutory denial (ANSI 96).

 

Last Updated Fri, 14 Jan 2022 18:12:51 +0000