Provider Notice Issued 11/18/2021

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Date:    November 18, 2021

To:       Enrolled Physicians; Advanced Practice Registered Nurses; Physician Assistants; Local Health Departments; Encounter Rate Clinics; Federally Qualified Health Centers; Rural Health Clinics; and School-Based Linked Health Centers

Re:      Professional Claims - Billing Procedure Code 99070 for Dispensing Fee for
            340B-Purchased Drugs Effective with Dates of Service Beginning December 1, 2021

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 This notice outlines a billing change related to the dispensing fee for 340B Program-purchased drugs. The change applies to professional claims billed under the fee-for-service (FFS) and HealthChoice Illinois managed care plan programs.

The FFS instructions below refer to billing actual acquisition cost (AAC) for 340B program drugs. These instructions are applicable to Encounter Rate Clinics (ERCs), Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) only for 340B-purchased long-acting reversible contraceptives (LARCs), which are billable FFS separately from a medical encounter, with scenario #1 in the examples that follow applicable to this situation. Providers are not required to use AAC when submitting MCO claims. 

Current FFS billing policy requires providers requesting dispensing fees for 340B drugs to submit the actual acquisition cost of the drug plus a drug dispensing fee ($12 non-family planning or $35 family planning) using the HCPCS drug code and modifier "UD", along with other applicable modifiers as described in the modifier listing:
FP – Family Planning
51 – Multiple Procedures
76 – Repeat Procedures by Same Practitioner
KQ - Second or Subsequent Drug of a Multiple Drug Unit Dose Formulation

National Drug Codes (NDCs) are reported on subsequent service lines. 

Changes Effective with Dates of Service on and after December 1, 2021:

• The provider's charge for the 340B drug HCPCS code should only encompass the actual acquisition cost of the drug. Providers are to continue to bill the HCPCS drug codes with the UD modifier (and any applicable FP, 51, 76, or KQ modifiers), with NDCs reported on subsequent service lines. 

• Providers must identify the dispensing fee separately under procedure code 99070 - Supplies and materials (except spectacles), provided by the physician or other qualified health care professional over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided). Providers must append 99070 with modifier FP when billing for family planning contraceptives.
  

• Multiple dispensing fees will be reimbursed based on the number of unique 340B HCPCS drug codes submitted for the same provider, same customer, and same date of service. Providers should bill 99070 with the unit quantity applicable to the number of unique HCPCS drug codes without the FP modifier on the claim, and/or bill 99070 with the FP modifier and the unit quantity applicable to the number of unique HCPCS drug codes with the FP modifier. Separate service lines are required for multiple billings of 99070 with and without the FP modifier. 

Examples of fee-for-service claim scenarios follow this notice. Questions regarding the notice can be directed to the Bureau of Professional and Ancillary Services at 877-782-5565, or to the applicable managed care plan.

Kelly Cunningham, Administrator
Division of Medical Programs

Scenario 1 

Provider bills a single drug code, which is a family planning drug.  Provider would also use this example for billing a single non-family planning drug, though without the FP modifier.

**This scenario, with the FP modifier, is applicable to ERCs, FQHCs and RHCs billing 340B-purchased LARCs FFS separately from a medical encounter** 

Scenario 2

Provider bills provider actual acquisition cost on two drugs and receives two dispensing fees. One drug is not a family planning drug and one is a family planning drug.

Scenario 3

Provider bills provider actual acquisition cost of one drug code but used two NDCs for the one drug.  Provider is entitled to one dispensing fee.  Provider is paid actual acquisition cost amount on the drug code and one dispensing fee. 

Scenario 4

Provider bills provider actual acquisition cost of two different drug codes, neither with the FP modifier.  Provider is entitled to two dispensing fees per NDC.  Provider bills the 99070 with applicable unit quantity of 2.  Provider is paid actual acquisition cost amount on the drug code and two dispensing fees.

Scenario 5

Provider bills acquisition cost and forgets to bill the dispensing code.  Provider receives acquisition cost only.

Scenario 6

Provider bills dispensing fee code without J drug code: reject. 

Provider must void J drug code payment (Scenario 4) and rebill with both codes on one claim.