Modifier Requirements Due To Lack of a Physicians Order - Modifier EY - JD DME

Jurisdiction D, Noridian Healthcare Solutions, has recently received inquiries regarding the proper submission of modifiers EY, GY and GA when a denial is anticipated due to the lack of a prescription. To reduce errors related to this process, it is important to remember that all durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items require a prescription (physician's order). Some DMEPOS items require a detailed written order prior to dispensing (WOPD), while others require a detailed written order (DWO) prior to billing. The specific requirements for an order are specified in the Medical Policy (Local Coverage Determination (LCD) and/or Policy Article) for the specific item.

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.

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.

However, 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 or, for non-Medicare insurers, is not a contract benefit") nor modifier GA is required when an item is expected to deny on the basis of a statutory denial (ANSI 96).

As a reminder, all items specified in MLN Matters 8304 which are subject to the Affordable Care Act 6407 require a WOPD. This is a statutory requirement. You must have received a complete WOPD that has been both signed and dated by the treating physician and meets the requirements for a DWO before dispensing the item. If you deliver the item prior to your receipt of a written order, it will be denied as statutorily noncovered. Therefore, when you do not have an order for these items, you must submit the claim with modifier EY. Again, neither modifier GY nor GA would be required.

We encourage you to refer to the LCD and related Policy Article for specific order and other documentation requirements for the items you provide.