OH – 340B Hospital Outpatient Modifier Required as of Oct. 1

October 2017 ~

Following a written statement to the Ohio Hospital Association from the Ohio Department of Medicaid’s (ODM) section chief, implementation of its 340B modifier requirement began as of October 1st.

According to the ODM, hospitals recognized as a 340B entity are required to notify Medicaid agencies when a 340B purchased drug is provided to a Medicaid individual so that the Medicaid agency does not claim a rebate for that drug as it was purchased through the 340B program.

Failure to inform a Medicaid agency that a 340B drug was used leaves the hospital vulnerable to audit findings should the Medicaid agency submit that drug for a rebate.

To avoid potential audit findings, providers should submit the SE modifier on the 340B drug detail line to indicate that a 340B drug was provided to a Medicaid individual (for dates of service on or after October 1st). The SE modifier should also be submitted on drug detail lines that contain a JW modifier (indicating drug waste).

The SE modifier must be listed within the first four modifiers submitted for that drug. Providers should use the SE modifier is appropriate in the following billing examples:

  • Revenue Code 25X, with a pharmaceutical J- or Q- code and an NDC
  • Revenue Code 636, with a pharmaceutical J- or Q- code and an NDC

Use of the SE modifier will inform the department that a 340B purchased drug was used and the department will automatically exclude those drug details from our rebate request. The ODM notes that drugs used during an inpatient stay are not eligible for the usage of 340B purchased drugs.

 

 

Source(s): Ohio Hospitals;

 

 

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