Reimbursement Facts

Most of the commercial payers and the State Medicaid programs across the country have developed their reimbursement policy for Mifeprex. In general, if surgical abortions are covered, the payer will most likely cover Mifeprex. There is no CPT code for the Mifeprex regimen. As a result, most payers will reimburse for each component separately.

For most payers, the charge for the three office visits should be submitted using the appropriate E/M code (e.g. 99204 or 99214 for Day 1, 99213 or 99214 for Day 3 and Day 14) as supported by the documentation in the medical record.
Most payers reimburse the cost of the drug using either an S code (S0190 for Mifeprex and S0191 for Misoprostol) or a J code (e.g. J8499 or J3490 which are the codes used for non-classified drugs). Payment is generally a pass through based on the actual invoice cost of the drug.
While ultrasound is not required, one or more ultrasounds may be useful to verify the date of pregnancy and to determine if the pregnancy has ended. Most payers reimburse for ultrasounds in accordance with their normal fee schedule. The appropriate code for an abdominal ultrasound is either 76805 or 76815; the appropriate code for a transvaginal ultrasound is 76830.

STATE-BY-STATE PAYER POLICIES

For information regarding specific payers in your state, select your state from the drop-down menu.

FREQUENTLY ASKED QUESTIONS

Q: How do I bill for the three office visits associated with the administration of Mifeprex?

A: Reimbursement policies vary by payer. Most payers, however, are reimbursing based on the submission of Evaluation and Management codes. The office visit level must be supported by documentation in the medical record. Check our state by state listing for more specific information and if your payer isn’t listed, call your provider representative at the payer.

Q: Do I receive any reimbursement for the administration of the drug?

A: There is no separate payment for administration. The payer generally reimburses you for the cost of the drug based on the actual invoice price.

Q: Should I submit each office visit claim at the time of service or should I submit them as a batch when the course of treatment is concluded?

A: Since it is not reimbursed as a global procedure, you can submit each bill separately as the service occurs.

Q: Can I order and bill for misoprostol in the same way that I do for Mifeprex?

A: Misoprostol can be ordered directly from Danco's authorized distributor at the same time you place an order for Mifeprex. Other distributors may also carry misoprostol. Generally, you can also bill for misoprostol using an S code (S0191) or a miscellaneous J code (J8499 or J3490).

Ask Your Reimbursement Question

If you have reviewed the reimbursement information on this site and you still have questions, please feel free to send us an e-mail with your questions to info@earlyoptionpill.com. We will respond as soon as possible.

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