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Provider Noticed issued 04/23/12

Procedure Code S5190

To:​ Federally Qualified Health Centers (FQHC), Encounter Rate Clinics (ERC) and Rural Health Clinics (RHC)​
​Date: ​April 23, 2012
​Re: 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.


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





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


Illinois Department of Healthcare and Family Services

JB Pritzker, Governor • Theresa Eagleson, Director

We improve lives.