Modifier EY is a Medicare HCPCS Level II modifier that indicates no physician or other licensed health care provider order exists for the item or service being billed.

For most Durable Medical Equipment (DMEPOS) items, Medicare requires a valid Standard Written Order (SWO) or other applicable practitioner order before the supplier furnishes the equipment and submits a claim. When a supplier submits a claim without the required order, Modifier EY may be appended to inform Medicare that no qualifying order exists.

Modifier EY does not create coverage or override Medicare policy. Instead, it accurately reflects that a required order is missing. Claims reported with Modifier EY are generally expected to be denied because Medicare requires a valid order for most covered DMEPOS items.

Modifier

Modifier Name

No Physician or Other Licensed Health Care Provider Order for This Item or Service

Plain English Explanation

Modifier EY tells Medicare:

“This claim is being submitted without a valid physician or other qualified licensed health care provider order for the billed item or service.”

It informs the payer that one of Medicare’s basic coverage requirements has not been met.

Purpose of Modifier EY

Modifier EY is used to:

Indicate that no valid practitioner order exists.
Accurately report the claim status to Medicare.
Allow Medicare to process and deny the claim when required.
Facilitate coordination of benefits when another payer requires a Medicare determination.
Support accurate claim reporting.

Understanding Modifier EY

Most Medicare-covered DMEPOS items require a valid order before the equipment is furnished.

The order may be:

A Standard Written Order (SWO) (current Medicare requirement for most DMEPOS items).
Another valid practitioner order when permitted by Medicare policy.

If the required order is missing at the time of claim submission, the supplier should understand that:

Medicare coverage requirements have not been met.
Payment is generally not expected.
Modifier EY accurately communicates the absence of the required order.

When to Use Modifier EY

Use Modifier EY when:

No physician or qualified licensed health care provider order exists.
Medicare policy requires an order before billing.
The supplier is submitting the claim despite the missing order (for example, to obtain a Medicare denial for coordination of benefits).
Medicare instructions identify EY as the appropriate modifier.

Examples include:

A wheelchair furnished before a valid order is obtained.
CPAP equipment delivered before the prescribing practitioner issues the required order.
A hospital bed provided without a completed Standard Written Order.
Orthotic or prosthetic items furnished before the required order is received.

When NOT to Use Modifier EY

Do not use Modifier EY when:

A valid Standard Written Order is on file.
The required physician order has been obtained before billing.
Another modifier more accurately describes the billing situation.
Medicare coverage requirements have been fully satisfied.

Medicare Rules

Under Medicare:

Most DMEPOS items require a valid Standard Written Order before billing.
Suppliers are responsible for obtaining required documentation.
Modifier EY indicates that the required order is not available.
Claims submitted with Modifier EY are generally expected to be denied because a required order is missing.
Modifier EY does not replace Medicare documentation requirements.

Commercial Insurance Rules

Commercial payer policies vary.

Some commercial insurers:

Require physician orders similar to Medicare.
Accept electronic orders.
Require prior authorization in addition to practitioner orders.
Do not recognize Modifier EY.

Always verify payer-specific documentation requirements before billing.

Documentation Requirements

When Modifier EY is reported, documentation should include:

Internal documentation showing that no qualifying order was available at the time of billing.
Medical records, if available.
HCPCS code.
Modifier EY.
Supplier documentation.
Any correspondence with the ordering practitioner.
Proof of delivery, if applicable.

Best Practice: Obtain the required practitioner order before furnishing the item whenever possible.

Real Billing Examples

Example 1 – Wheelchair Without an Order

A supplier delivers a standard wheelchair before receiving the physician’s Standard Written Order.

Billing

Appropriate HCPCS code
Modifier EY

Medicare is expected to deny the claim because the required order is missing.

Example 2 – CPAP Device

A CPAP device is delivered before the prescribing practitioner completes the required order.

Billing

HCPCS E0601
Modifiers RR EY

Example 3 – Hospital Bed

A beneficiary urgently needs a hospital bed, but the physician order has not yet been completed.

Billing

Appropriate HCPCS code
Modifier EY

Example 4 – Secondary Insurance Requirement

A supplier submits the claim to Medicare with Modifier EY to obtain a denial before billing a secondary insurance carrier.

Example 5 – Incorrect Use

A supplier has a valid Standard Written Order in the patient’s file but still reports Modifier EY.

This is incorrect because Modifier EY should only be used when no qualifying order exists.

CMS-1500 Claim Example

Field	Example
HCPCS	E0601
Modifier 1	RR
Modifier 2	EY
Diagnosis Pointer	Appropriate ICD-10-CM diagnosis
Units	1

Common Denial Reasons

Missing physician or practitioner order.
No Standard Written Order (SWO) on file.
Incorrect use of Modifier EY.
Incomplete documentation.
HCPCS code requires an order before billing.
Missing supporting medical records.

How to Correct the Denial

Obtain a valid physician or qualified practitioner order.
Verify that the order meets Medicare requirements.
Review the applicable LCD or DME MAC policy.
Correct the modifier if appropriate.
Resubmit the claim or appeal when permitted with the required documentation.

Coding Tips

Obtain the Standard Written Order before furnishing DME whenever required.
Do not use EY when a valid order exists.
Review current CMS and DME MAC ordering requirements.
Maintain complete supplier documentation.
Understand that EY generally results in a claim denial.

Modifier EY vs Modifier KX

Modifier	Description
EY	No physician or practitioner order exists
KX	Coverage requirements and required documentation have been met

Modifier EY vs Modifier GA

Modifier	Description
EY	No required practitioner order
GA	Valid ABN obtained before furnishing a potentially non-covered covered item

Modifier EY vs Modifier GZ

Modifier	Description
EY	Required practitioner order is missing
GZ	No ABN on file for an item expected to be denied as not reasonable and necessary

Modifier EY vs Modifier GY

Modifier	Description
EY	Covered item lacks the required order
GY	Item is statutorily excluded or not a Medicare benefit

Frequently Asked Questions (FAQs)

Q1. What does Modifier EY mean?

Answer: It indicates that no physician or other qualified licensed health care provider order exists for the billed item or service.

Q2. Does Modifier EY guarantee claim denial?

Answer: It does not automatically guarantee a denial, but because a required order is generally a condition of Medicare coverage, claims submitted with Modifier EY are typically denied unless another payer rule applies.

Q3. Can EY be used when a Standard Written Order exists?

Answer: No. Modifier EY should only be reported when the required order is not available.

Q4. Is Modifier EY used only for Medicare?

Answer: It is primarily a Medicare HCPCS modifier. Commercial payer recognition varies.

Q5. Can Modifier EY be used with RR?

Answer: Yes. For example, a rented DME item may be billed with RR and EY if no required practitioner order exists, although the claim is generally expected to be denied.

AR Caller Tips

When following up on claims billed with Modifier EY:

Verify whether a Standard Written Order has since been obtained.
Confirm the order date and practitioner signature.
Review Medicare denial reason codes.
Ask whether the claim can be corrected after obtaining the required documentation.
Document the payer representative’s name, reference number, and appeal instructions.
Educate intake staff about obtaining practitioner orders before dispensing DME.

Interview Questions

Question 1

What does Modifier EY indicate?

Answer: No physician or qualified licensed health care provider order exists for the billed item or service.

Question 2

What document is commonly required before billing Medicare for DMEPOS items?

Answer: A valid Standard Written Order (SWO) or other Medicare-approved practitioner order.

Question 3

Does Modifier EY satisfy Medicare documentation requirements?

Answer: No. It simply reports that the required order is missing.

Question 4

Can a claim with Modifier EY be corrected later?

Answer: If Medicare policy permits and a valid order is subsequently obtained, the supplier may be able to submit a corrected claim or appeal with appropriate documentation, subject to timely filing and payer rules.

Practice Scenario

Scenario

A supplier delivers a Medicare-covered hospital bed before receiving the physician’s Standard Written Order. The supplier submits the claim to Medicare because a secondary payer requires a Medicare determination.

Question

Which modifier should be reported?

Answer

Report the appropriate HCPCS code with Modifier EY, indicating that no physician or qualified licensed health care provider order existed at the time the claim was submitted.

Related DME Modifiers

KX – Requirements Specified in the Medical Policy Have Been Met
GA – Waiver of Liability Statement Issued as Required by Payer Policy
GZ – Item or Service Expected to Be Denied as Not Reasonable and Necessary; No ABN on File
GY – Item or Service Statutorily Excluded or Does Not Meet the Definition of a Medicare Benefit
RR – Rental Durable Medical Equipment
NU – New Durable Medical Equipment Purchase
UE – Used Durable Medical Equipment Purchase

Common Billing Mistakes

Furnishing DME before obtaining the required practitioner order.
Reporting EY even though a valid order exists.
Confusing a missing order with a medical necessity denial.
Failing to maintain communication records with the ordering practitioner.
Assuming EY overrides Medicare documentation requirements.
Missing timely filing deadlines while waiting for an order.

Key Takeaways

Modifier EY indicates that no physician or qualified licensed health care provider order exists for the billed item or service.
It is primarily used in Medicare DMEPOS billing.
Most claims reported with EY are expected to be denied because a required coverage condition has not been met.
EY does not replace the need for a valid Standard Written Order.
Accurate documentation and timely order collection are essential for successful Medicare reimbursement.

References

CMS Medicare Claims Processing Manual, Chapter 20 – Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).
CMS Medicare Program Integrity Manual – Ordering and Documentation Requirements.
Medicare Benefit Policy Manual.
DME Medicare Administrative Contractor (DME MAC) Supplier Manuals.
HCPCS Level II Code Book.

Conclusion

Modifier EY is a Medicare DMEPOS modifier that indicates no physician or other qualified licensed health care provider order exists for the billed item or service. It alerts Medicare that a fundamental documentation requirement has not been met and generally results in claim denial. Suppliers should use Modifier EY only when appropriate, obtain valid practitioner orders as early as possible, and maintain complete documentation to ensure compliance with Medicare billing requirements.

Educational Disclaimer

This article was prepared with the assistance of artificial intelligence (AI) for educational and informational purposes. It is based on publicly available CMS guidance, Medicare DMEPOS documentation requirements, and general medical coding practices. It is not an official publication of CMS or the American Medical Association (AMA). Always consult the latest CMS Medicare Claims Processing Manual, the Medicare Program Integrity Manual, the HCPCS Level II Code Book, applicable DME Medicare Administrative Contractor (DME MAC) guidance, Local Coverage Determinations (LCDs), and payer-specific billing policies before coding, billing, or submitting claims.