Provider Noticed issued 04/23/12

Procedure Code S5190

The purpose of this notice is to inform encounter rate clinics, Provider Types 40 (Federally Qualified Health Centers), 43 (Encounter Rate Clinics) and 48 (Rural Health Clinics), to utilize procedure code, S5190, Wellness Assessment, Performed by a Non-Physician when an office visit does not meet the requirements of a face-to-face encounter. No payment for these services will be generated.

Clinic claims submitted with procedure code, S5190, must contain at least one additional covered procedure code (i.e., CPT, HCPCS) reported in the detail lines. The rendering provider name and NPI are not required on claims submitted with procedure code, S5190.

Example:

Service Line 1 or Loop 2400: S5190 – Wellness Assessment

Service Line 2 or Loop 2410: 90xxx – Specific Vaccination

Do not submit S5190 on the same claim form with any of the following codes:

T1015 - Clinic Visit/Encounter, All-Inclusive

Evaluation and Management Codes

99201-99205

99211-99215

99381-99385

99391-99395

Billing of any of these procedure codes on the same claim as S5190 will cause the claim to reject with error code H47, Procedure Code Combo Not Allowed.

Questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator

Division of Medical Programs