HCPCS code S0190 – Mifepristone billing and reimbursement

Key takeaways

HCPCS code S0190 bills mifepristone, oral, 200 mg, and one unit equals one 200 mg tablet rather than the full regimen.

S codes are temporary national codes that are not valid for Medicare, so Medicaid, commercial plans and self-pay are the routes that pay.

Every S0190 claim needs an 11-digit NDC, and a missing or invalid NDC is a common cause of outpatient drug claim rejection.

Medicaid coverage depends on the state, but federally required life, rape and incest exception cases remain billable everywhere.

Pabau, the practice management platform we build, submits CMS-1500 claims through Claim.MD and tracks claim status and remittances.

What is HCPCS code S0190?

HCPCS code S0190 is the Level II code for mifepristone, oral, 200 mg, billed per tablet dispensed in a physician office, practice or outpatient pharmacy. CMS’s October 2026 HCPCS file lists S0190 under that descriptor with coverage code I, not payable by Medicare. CMS publishes the HCPCS Level II file. Meanwhile, S codes are temporary national codes used mainly by Medicaid and commercial payers.

First, the quick-reference facts for S0190 are summarized below.

Official code descriptor and clinical overview

Specifically, the official descriptor, mifepristone, oral, 200 mg, captures exactly what S0190 bills. In other words, that is the drug itself, dispensed orally at the standard 200 mg dose. Likewise, it does not capture misoprostol, counseling, the office visit, or any procedural part of the abortion service.

Mifepristone blocks progesterone receptors and, combined with misoprostol, ends a pregnancy up to 70 days of gestational age. In addition, the FDA approved it in 2000 under a Risk Evaluation and Mitigation Strategy (REMS) program. Therefore, prescribers and dispensers must be REMS-certified before the drug can legally be prescribed or dispensed.

Moreover, REMS certification is a billing prerequisite as well as a clinical one. In fact, payers audit REMS compliance during post-payment review, and claims from uncertified providers may be subject to recoupment. As a result, coders who treat S0190 as a simple drug code can miss this part of the claim.

S0190 does not include:

• Misoprostol, which is billed separately as S0191
• Physician office visit E/M services (bill the appropriate CPT E/M code)
• Patient counseling or informed consent services
• Ultrasound confirmation of gestational age
• Follow-up visit to confirm complete abortion

S0190 fee schedule and reimbursement rates (2026)

S0190 reimbursement rates are set at the payer level, not by a CMS national fee schedule, because S-series codes are not valid for Medicare. As a result, the CMS Physician Fee Schedule lookup tool will not return a rate for S0190. Instead, individual Medicaid programs and commercial payer contracts set the rates.

To find your state Medicaid rate for S0190, first query the fee schedule in your state’s Medicaid management information system (MMIS). However, rates vary widely. Some states pay acquisition cost plus a dispensing fee, while others use a standard drug reimbursement formula.

Verify the current rate before billing. After all, state Medicaid agencies update fee schedules on their own timetable, separate from the CMS annual cycle.

Payer coverage and prior authorization for mifepristone billing

Prior authorization for S0190 depends on the payer, so no universal rule exists. Some commercial plans require it, while others cover mifepristone under the pharmacy benefit without it. Medicaid programs in covering states generally do not require it, though exceptions exist.

Each payer type sends an S0190 claim down a different route, so four checks apply on every route.

In fact, REMS certification is a universal prerequisite. Still, even where prior authorization is not required, payers may ask for proof of prescriber and dispenser REMS enrollment during claims review. Keep the following on file for every S0190 claim:

• Prescriber REMS certification and the date it was completed
• Dispenser (pharmacy or practice) REMS certification
• Signed Patient Agreement Form (REMS) retained in the chart
• PA reference number where the payer requires prior authorization

Also, payers that exclude medication abortion deny S0190 as a non-covered service, whatever the documentation shows. However, the denial code (CO-96 or CO-27) will not mention REMS. When the patient has a Medicaid plan in a restricted state, confirm coverage before the visit and document any life, rape or incest exception.

How to bill HCPCS code S0190 correctly

Accurate S0190 billing follows a consistent workflow. In fact, errors in units, NDC format, or place of service are the easiest rejections to correct before the claim reaches a payer adjudicator.

1. Units: First, report 1 unit per 200 mg tablet dispensed. The standard medication abortion regimen uses one 200 mg mifepristone tablet, so a standard dispense is 1 unit. Never report units as milligrams, because the descriptor already sets 200 mg per unit.
2. NDC submission: Next, submit the 11-digit NDC in the NDC qualifier field. That matters because Medicaid programs require the 11-digit format (5-4-2 segment structure). Then convert the 10-digit NDC on the package to 11 digits by adding a leading zero to the correct segment.
3. Place of service: Then use POS 11 (office) for an in-office dispense. Instead, use POS 22 (on campus-outpatient hospital) or POS 19 (off campus-outpatient hospital) for hospital outpatient settings. Also, POS affects the allowable rate on some payer contracts.
4. Claim form: Also, use the CMS-1500 (professional claim) for physician offices and practices, and the UB-04 for hospital outpatient departments. On the CMS-1500, for example, the HCPCS code and NDC go in Box 24. In addition, Pabau’s US claims management submits CMS-1500 claims through Claim.MD and tracks status and remittances.
5. Diagnosis code linkage: Finally, link the appropriate ICD-10-CM diagnosis code (see the ICD-10 section below) in the diagnosis pointer field on the claim form.

NDC to HCPCS crosswalk for mifepristone

Two manufacturers produce mifepristone products that crosswalk to S0190. Specifically, they are Danco Laboratories (brand name Mifeprex) and GenBioPro (generic mifepristone). Both map to S0190, because the HCPCS code captures the drug and strength rather than the manufacturer.

Confirm the NDC for the product you dispense against the current FDA-approved labeling before you submit.

NDC numbers change when packaging changes. Therefore, check the NDC printed on the label against your dispense record, not a static crosswalk table.

Modifiers used with S0190

First, no modifier is required by default. Still, append JW or JZ only where a specific payer’s policy requires it. Both are Medicare Part B single-dose-container modifiers, so they rarely fit an oral tablet billed under a non-Medicare S code. Oral minoxidil under code S0139 follows the same rule, billed in 10 mg units with no waste modifier.

Mifepristone is dispensed as a single prepackaged 200 mg tablet, so drug wastage is uncommon for a standard dispense. If a payer’s drug policy does call for JZ on all drug claims, append it to the S0190 line for that payer only.

ICD-10 diagnosis codes to report with S0190

Also, S0190 must be linked to a supported ICD-10-CM diagnosis code on the claim. Thus, the diagnosis code documents why mifepristone was dispensed. Furthermore, payers cross-check the diagnosis against the drug code, and an unsupported combination denies automatically.

For example, Z33.2 is the primary diagnosis for an elective medication abortion billed with S0190. Confirm the diagnosis against the clinical record before coding. However, payers that restrict medication abortion coverage deny S0190 whatever the diagnosis code.

Related codes: What to bill alongside S0190

However, S0190 covers only the mifepristone tablet. Therefore, a complete medication abortion visit generates other billable services, each with its own code. As a result, knowing what each companion code captures prevents unbundling errors and missed charges.

A payer that accepts S0199 expects it in place of the itemized services, so check the contract before you build the claim. Where a payer wants itemized billing instead, the visit goes on as 99213 or 99214 and the dating scan as 76801.

Reviewing the full medical billing workflow for reproductive health services helps billing teams identify every chargeable component before the encounter. Otherwise, teams end up reconstructing charges during charge capture.

Common claim denial reasons for S0190

S0190 denials cluster around six predictable causes, but each one needs a different fix. Therefore, matching the remark code to the cause is faster than a generic appeal.

Also, the denial codes guide explains each claim adjustment and remark code in this table, including M119. Read the remark code first, because CO-16 alone does not say which field failed.

Systematic denial management for drug codes like S0190 catches NDC and unit errors at claim creation rather than after remittance. For example, a pre-submission check for 11-digit NDC presence and unit counts stops both errors before the claim leaves your practice.

Documentation requirements for S0190 claims

The documentation behind an S0190 claim must show two things. First, the chart must show that mifepristone was clinically appropriate. Second, it must show that the provider was eligible to prescribe and dispense it, which post-payment audits of REMS drugs check closely.

Required documentation in the medical record:

• Prescriber REMS certification: The signed Prescriber Agreement Form or certification record from the REMS program. Also, it must match the NPI on the claim.
• Dispenser REMS certification: If the drug is dispensed in-office, the practice or pharmacy must also hold REMS certification. Therefore, keep it on file for audit.
• Gestational age documentation: Clinical confirmation that gestational age is within the 70-day approved indication, recorded in the medical record.
• Patient agreement form: The signed FDA Patient Agreement Form that the REMS requires, retained in the chart.
• Dispense record: Quantity dispensed, NDC, lot number, and expiration date, recorded at the time of dispensing.
• Diagnosis documentation: Clinical notes supporting the billed ICD-10-CM code. For Z33.2, for example, the note should clearly reflect the encounter type.
• PA reference number: Where prior authorization was required, record the PA reference number in the chart and on the claim.

As a result, a documentation checklist for each S0190 encounter reduces audit exposure. In addition, medical billing compliance for drug codes requires the chart and the claim line to tell the same story. Specifically, quantity, NDC, and indication must agree in both.

State-by-state Medicaid coverage for mifepristone billing

State Medicaid coverage for mifepristone varies more than any other part of S0190 billing. Since Dobbs, states fall into three broad categories, and the category decides how S0190 is billed to Medicaid.

Coverage status changes as state laws are enacted, challenged, and revised. Therefore, check the AAPC HCPCS code lookup and your state Medicaid agency’s provider portal for current S0190 coverage. Never assume coverage from a prior billing cycle. Instead, verify it each January and whenever state legislation changes. Codes in the S-series can also be deleted outright, as S0162 for efalizumab was in 2009.

How Pabau keeps S0190 claims and REMS records together

S0190 rework often starts outside the claim. For example, the NDC sits on a dispense log and the Patient Agreement Form in a paper file. Then the denial arrives weeks later in a separate inbox.

Instead, Pabau, the practice management platform we build, keeps those pieces on one patient record. Its remittance-tracking claims management submits CMS-1500 claims through Claim.MD and runs eligibility checks before the visit. Also, ERA remittances post back against the claim, and secondary claims go out from the same screen.

In addition, digital forms let patients sign the Patient Agreement Form before the appointment, and the signed copy stays in the chart for audits. When a payer denies an S0190 line, your billing team sees the remittance next to the visit it belongs to.

Keep S0190 claims and REMS records together

Pabau’s claims management submits CMS-1500 claims through Claim.MD and tracks status and remittances. Digital forms keep the signed REMS paperwork in the patient chart.

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Conclusion

S0190 itself is simple to code: one unit per 200 mg tablet, with an 11-digit NDC. However, payment depends on what surrounds the code, so settle the payer route before the patient arrives.

Check whether the state Medicaid program or the commercial contract covers the drug, and whether the payer wants S0199 for the episode. Keep the REMS certification and the signed Patient Agreement Form on file, because post-payment reviews look for both.

Book a demo to see how Pabau keeps S0190 claims, signed REMS forms and remittances on one patient record.

Continue your research

Need a full picture of outpatient drug billing? Medical billing fundamentals covers charge capture, claim submission, and remittance workflows for outpatient practices.

Seeing S0190 denials pile up? Denial codes in medical billing explains the common CARC and remark codes and how to resolve each one.

Billing the dating ultrasound separately? CPT code 76801 covers the first-trimester pregnancy ultrasound and the documentation it needs.

Building a compliance routine for drug claims? Medical billing compliance sets out the audit, documentation, and coding controls that keep claims defensible.

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