The G0402 HCPCS code needs full understanding by healthcare providers, along with beneficiaries enrolled in Medicare. G0402 identifies the Initial Preventive Physical Examination, also known as Medicare’s Welcome to Medicare visit. The crucial healthcare offer assists Medicare enrollees in establishing proper medical care during their first membership period.
We will provide a complete examination of the G0402 HCPCS code that explains its definition, together with eligibility requirements, billing procedures, and their importance for healthcare providers and Medicare beneficiaries.
What Is the G0402 HCPCS Code?
The Initial Preventive Physical Examination (IPPE) has its HCPCS code labeled as G0402.
The Medicare “Welcome to Medicare” visit operates under the G0402 HCPCS Code. The face-to-face service provided by G0402 exists exclusively for Medicare patients starting their coverage. Medical providers are restricted to using G0402 for beneficiary evaluations between Medicare enrollment and the first 12 months of membership.
During the 12-month enrollment period for new Medicare beneficiaries, the healthcare system provides a single comprehensive preventive medical check-up known as the Initial Preventive Physical Examination.
- Code: G0402
- Service: Initial preventive physical exam
- Provider: Physician or qualified non-physician practitioner (NPP)
- Eligibility: Medicare Part B beneficiary within 12 months of enrollment
- Cost to Patient: Most patients pay no costs when using a provider who accepts assignment.
Medicare has created this evaluation to serve as its health examination program for screening new members.
Why Is the G0402 Code Important?
Such healthcare services require the G0402 code because it promotes early preventive care for elderly patients. This code helps providers achieve all the following:
- Identify health risks early.
- Educate patients on lifestyle changes.
- Schedule appropriate screenings and vaccinations.
- Improve patient outcomes through prevention.
Medicare Part B completely covers the expenses of a G0402 visit, making the examination fee free for patients.
Correct billing of G0402 leads to necessary reimbursement for providers and enables proper preventive care delivery.
What’s included in the G0402 Visit?
Within the first 12 months of their Medicare enrollment period, new beneficiaries have access to one initial preventive physical examination (IPPE) called G0402 or “Welcome to Medicare” medical service based on face-to-face interaction.
1. Review of Medical and Social History
The medical professional examines the entire clinical background, including family medical information, alongside surgical procedures. Evaluation consists of healthcare practices like dietary habits alongside present drug use and supplements, as well as alcohol consumption, together with tobacco usage and drug consumption, and exercise routines.
The main objective involves recognizing health factors that can be modified so patients can achieve better health outcomes45.
2. Assessment of Mental Health and Functional Status
During the visit, healthcare providers conduct depression and other mood disorder screenings through acceptable diagnostic instruments. The provider conducts tests to evaluate safety risks with an emphasis on hearing disabilities and home safety needs and functional abilities, such as daily task performance and fall dangers45.
3. Focused Physical Examination
The physical examination differs from standard checks by having this specialized approach with the following assessment points:
- Height
- Weight
- Body mass index (BMI)
- Blood pressure
- Visual acuity screening (e.g., Snellen chart)
The physical examination should include additional components which selected based on the patient’s historical information and potential risks.
4. End-of-Life Planning
Healthcare staff disclose and distribute written advance directive content to patients who volunteer their consent. Clinical staff clarify with patients their capacity to create healthcare instructions during inability-to-make-decision states as well as the provider’s commitment to follow patients’ decisions45.
5. Education, Counseling, and Referral
The provider provides brief educational counseling after gathering information from history, exams, and assessments.
The session educates patients about dietary measures while instructing them on handling their chronic medical condition and establishes plans to prevent smoking as well as alcohol misuse and additional wellness practices. The provider will refer patients to specialists in addition to making preventive service referrals as needed.
6. Preventive Services Planning
Following the discussion, the provider creates written documentation for other Medicare-covered preventive services that need to be provided to the patient. The beneficiary can receive covered screenings, including mammograms as well as colonoscopies, and immunizations, alongside other Part B-covered preventive services.
G0402 vs. G0438 vs. G0439: What’s the Difference?
| Code | When to Use | Who’s Eligible | What’s Covered |
| G0402 | First 12 months of Medicare | New beneficiaries | Initial preventive physical exam (IPPE) |
| G0438 | After 12 months, the first AWV | Year 2+ beneficiaries | Annual Wellness Visit (first) |
| G0439 | Each year after G0438 | Returning beneficiaries | Annual Wellness Visit (subsequent) |
Who Can Bill for G0402?
Only authorized healthcare professionals who received Medicare approval to conduct the Initial Preventive Physical Examination (IPPE) can submit billings for the G0402 HCPCS code. Here’s the breakdown:
Authorized Providers
1. Physicians (MD/DO)
Only doctors holding either MD or DO credentials can conduct Initial Preventive Physical Examinations, resulting in G0402 billing. All staff must conduct the face-to-face encounter, followed by complete documentation of the provided services.
2. Physician Assistants (PAs)
The service provider performs G0402 billing under the supervision of physicians through established collaborative agreement protocols.
3. Nurse Practitioners (NPs)
NPs hold the authority to execute G0402 billing directly in states that permit full practice authority for NPs.
4. Certified Clinical Nurse Specialists (CNSs)
The providers need to fulfill all requirements set by Medicare to be eligible for billing directly.
5. Medical Professionals Under Direct Physician Supervision
Medical staff can help during patient visits, provided the physician maintains billing ownership through their name.
Key Rules for Billing G0402
- Timing: Only during the patient’s first 12 months of Medicare enrollment17.
- Documentation: The documentation needs to contain all necessary elements that include medical history screening and preventive planning, and risk assessment.
- Modifiers: Doctors ought to apply the -25 modifier in situations where they need to charge separately for an E/M service, such as 99213, while treating different clinical concerns within a single patient encounter.
- Exclusions: The billing of comprehensive preventive exam CPT codes 99381-99397 is prohibited when performing G0402 services.
When residents participate in a visit payment, they need to use modifiers GE or GC to show their status under a teaching physician.
Billing Requirements for G0402 HCPCS Code
Healthcare providers must follow strict rules when they need to correctly bill Medicare for G0402 Initial Preventive Physical Examination (IPPE)—known as the “Welcome to Medicare” visit. Here’s what you need to know:
Timing Requirements
- Eligibility Window: Patients who enroll in Medicare Part B have 12 months to receive reimbursement for benefits services.
- Denial Risk: Any claims filed for G0402 after the 12 months will automatically result in rejection by the system 46.
Documentation Components
Healthcare providers must integrate the following features in the patient meeting.
- Medical/social history review (lifestyle, medications, family history).
- Vital measurements: Height, weight, BMI, blood pressure, vision screening.
- Risk assessments: Depression, functional ability, fall risks.
- Preventive care plan: Documentation of important future tests, including vaccines and mammograms, exists in the patient record.
- End-of-life planning (optional but recommended).
Billing Process
- Primary Code: Use G0402 for the IPPE. The IPPE should employ diagnostic code Z00.00 for a general adult examination or prevent any ICD-10 diagnostic codes.
- Modifier -25: The use of Modifier -25 requires the addition to the E/M codes, such as 99213, when you treat new problems within the same medical encounter. The billing of EKG tests should be done separately using either the G0403 code for full EKGs, the G0404 code for tracings, or the G0405 code for interpretation when these tests are referred during the IPPE.
The screening EKG procedure has a lifetime coverage restriction that allows just one EKG exam per patient.
Prohibited Billing Practices
The Annual Wellness Visit codes G0438/G0439 must not be billed when G040213 appears within 12 months of each other.
- Avoid CPT 99381-99397: G0402 and related codes belong to routine physical care, which differs from IPPE67.
- Resident Billing: Use modifiers GE (resident service) or GC (teaching physician supervision) if applicable
Reimbursement Rules
- No Patient Cost: The medical procedure G0402 falls completely under Medicare Part B without requiring patient contributions or deductibles, or copayments.
- E/M Services: The beneficiary needs to pay the cost-sharing amount only when doctors apply modifier -25.
- Denial Triggers: The denial of reimbursement occurs when service timing is incorrect and when duplicate claims exist, or when needed documentation is absent.
Is it possible to bill extra services when using G0402?
Yes! The practice can submit individual payments for medically required services you perform during an IPPE.
For example:
New problems that require Evaluation and Management (E/M) services should include modifier -25 on the claim.
The screening tests, including EKGs using G0403, G0404, and G0405, have limited coverage to one lifetime screening, but insurers can pay for individual tests. Document every service you provide to bill multiple services during a single appointment correctly.
Conclusion
The G0402 Health Care Financing Administration procedure code functions as a vital instrument in Medicare preventive care. The system helps providers and patients through its promotion of complete and timely health checks at early stages. Healthcare providers receive an exceptional opportunity to detect health risks through preventive examinations, which establish patient trust in their new Medicare relationship while establishing fundamental healthcare measures.
- Providers must ensure the following steps for G0402 HCPCS code documentation and billing.
- Medical professionals need to recognize patients eligible for G0402 service during the initial 12-month period of receiving Medicare coverage.
- All mandatory requirements of the IPPE need to be completed.
- The proper documentation and billing procedure require using G0402.
As a newcomer to Medicare benefits, you should seize the opportunity for the “Welcome to Medicare” appointment.
Starting this visit marks your beginning path toward better health.