Reimbursement Codes

Most of the commercial payers and the state Medicaid programs across the country have reimbursement policies for Mifeprex*. In general, if surgical abortions are covered, the payer is also covering Mifeprex.

There is no bundled CPT code for the Mifeprex regimen. As a result, most payers are reimbursing for each component separately.

Almost all the payers are now using the S codes, S0190 for Mifeprex and S0191 for misoprostol, to reimburse for the drugs. Payment is generally a pass through based on the actual invoice cost of the drug.

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.

While ultrasound is not required as part of the regimen, one or more ultrasounds may be useful to verify the date of pregnancy and to determine if the pregnancy has ended. Most payers have indicated that they will reimburse for ultrasounds in accordance with their normal fee schedules. The appropriate code for an abdominal ultrasound is either 76805 or 76815; the appropriate code for a transvaginal ultrasound is 76830.

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.

Q: Where can I find reimbursement information specific to my state?

A:

Check our state-by-state listing for detailed information. If your payer is not listed, email us at info@earlyoptionpill.com.

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

A:

There is no separate payment for administration of Mifeprex. The payer will generally reimburse you for the cost of the drug based on the actual invoice price. The payer will also reimburse you for additional services, such as office visits and ultrasound.

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 being 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. Although it varies by insurance company, you can generally bill for misoprostol using the code S0191.

Ask Your Reimbursement Question

If you have additional questions regarding reimbursement for Mifeprex, please call us at 1-877-4 Early Option (1-877-432-7596).