Summary & Overview
HCPCS G0402: Initial Preventive Physical Examination, New Medicare Beneficiary
HCPCS Level II code G0402 represents the Initial Preventive Physical Examination — a face-to-face visit delivered to new Medicare beneficiaries within their first 12 months of enrollment. Nationally, this code matters because it supports early preventive assessment and care planning for a high-risk population segment, and it is tied to Medicare coverage policies that shape provider workflows and billing practices. Key payers in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
Readers will learn what the code represents clinically, which payers commonly encounter it, and the policy and billing context that influences its use. The publication provides benchmarks and operational guidance on claim categorization and expected sites of service, summarizes relevant policy updates affecting preventive visit coverage, and explains how G0402 fits within broader preventive care workflows. Data not available in the input is noted where applicable. The write-up is intended for national audiences including billing managers, policy analysts, and clinicians responsible for preventive care workflows and Medicare enrollment-period services.
Billing Code Overview
HCPCS Level II code G0402 denotes an Initial preventive physical examination; face-to-face visit provided to a new Medicare beneficiary during the first 12 months of Medicare enrollment. The service is a focused, one-time preventive visit intended to establish baseline health, review medical and social history, screen for preventive services, and develop a preventive care plan.
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Service type: Initial preventive physical examination (preventive/wellness clinical visit)
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Typical site of service: Office or other outpatient clinical setting where face-to-face evaluation and counseling can be provided
Clinical & Coding Specifications
Clinical Context
A 67-year-old Medicare beneficiary enrolls in Part B and schedules an initial preventive physical examination within the first 12 months of enrollment. The visit is a face-to-face, comprehensive encounter with a primary care clinician to review medical history, preventive care needs, medication review, and baseline vitals. Typical workflow: patient registration verifies Medicare Part B effective date; front-desk staff flags the chart for an Initial Preventive Physical Examination billed with G0402; nursing completes vitals, medication list, and initial screening (e.g., fall risk, depression screening); clinician performs a focused physical exam, reviews preventive services (immunizations, cancer screenings), documents counseling and any orders (labs, imaging, referrals); encounter note documents time, components, Medicare beneficiary status, and any separately reportable services. If additional medically necessary evaluation and management (E/M) services are provided beyond the scope of the preventive visit, documentation supports separate billing with an appropriate E/M CPT and modifier as applicable.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, separately identifiable E/M service on the same day as a procedure | Use when medically necessary evaluation beyond the preventive visit is documented and billed separately with a CPT E/M code |