HCPCS Modifier GY

Published 07/16/2020

Item or services statutorily excluded does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit.


  • Submit HCPCS modifier GY with items or services that are statutorily excluded or those that do not meet the definition of any Medicare benefit
  • Examples of services for which HCPCS modifier GY may be appropriate include: routine physicals, laboratory tests in absence of signs or symptoms and hearing aids
  • Both Medicare beneficiaries and providers have certain rights and protections related to financial liability under the Fee-for-Service (FFS) Medicare and the Medicare Advantage (MA) Programs. These financial liability and appeal rights and protections are communicated to beneficiaries through notices given by providers.
  • The revised Advanced Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131 (3/2011) may be used to provide voluntary notification of financial liability. Thus, this version of the ABN should eliminate any widespread need for the Notice of Exclusion from Medicare Benefits (NEMB) in voluntary notification situations.
  • The CMS ABN form is available at CMS website


  • CMS ABN (Form CMS-R-131) and instructions for completion

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