340B TB modifier reporting and payment for Part B drugs
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Defines Aspirus Medicare Advantage billing and payment expectations for drugs and biologicals acquired through the 340B Drug Pricing Program, including required use of modifier TB and related payment methodology for hospital outpatient services.
As of January 1, 2025, CMS requires all 340B covered entities to exclusively report modifier 'TB' on claim lines for drugs acquired through the 340B Drug Discount Program.
Effective for claims paid on or after September 28, 2022, Aspirus implemented payment updates to allow the full rate (generally ASP plus 6%) for 340B purchased drugs in accordance with CMS guidance.
Coverage and Payment Criteria
Aspirus 340B modifier and payment criteria
Coverage and payment stance for 340B-acquired Part B drugs and biologics furnished by hospitals paid under OPPS:
Payment methodology (date-dependent)
- For claims paid on or after 9/28/2022: Aspirus implemented payment updates to revert to allowing the full rate (generally ASP plus 6%) for 340B purchased drugs, in accordance with CMS guidance.
- For claims paid prior to 9/28/2022: Aspirus paid an adjusted amount equal to ASP minus 22.5% (a discount of 26.9% of the fee schedule rate) for certain separately payable 340B drugs/biologicals furnished by hospitals paid under OPPS.
Coding and Payment Dates
| TB | Drug or biological acquired with 340B Drug Pricing Program discount (informational) |
| JG | Formerly permitted 340B modifier; removed 12/31/2024 |
Provider Billing & Submission Requirements
340B claim submission: bill type 13x and mandatory -TB modifier
Submit outpatient Part B drug claims acquired through the 340B Program using bill type 13x and append the -TB modifier to each HCPCS line for drugs acquired through 340B; ensure the HCPCS is identified as eligible for 340B purchase and that payment is under hospital outpatient methodology. Note that CMS requires exclusive use of modifier TB on claim lines for separately payable Part B drugs acquired through 340B effective January 1, 2025 (JG was removed 12/31/2024).
- Use bill type 13x for 340B claims.
- Append modifier -TB to HCPCS lines for drugs acquired through the 340B Program.
- Identify the submitted HCPCS as eligible for 340B purchase.
- Ensure provider payment is based on hospital outpatient (OPPS) methodology.
- As of 1/1/2025, report TB exclusively; JG was removed from eligible modifiers 12/31/2024.
Key Definitions
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