HCPCS Code G0402

Official Description

Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment

Short Descr	Initial preventive exam
Coverage	Carrier Priced
Pricing Indicator(s)	11 – Physician Fee Schedule - Price established using national RVUs
MPI	A – Not applicable, as HCPCS priced under one methodology
Processing Note	PURSUANT TO SECTION 101 (B) OF THE MEDICARE IMPROVEMENT FOR PATIENTS AND PROVIDERS ACT OF 2008 (MIPPA) EFFECTIVE JANUARY 1, 2009, WE EXPANDED COVERAGE FOR THE WELCOME TO MEDICARE BENEFIT; IT IS SUBJECT TO CERTAIN ELIGIBILITY AND OTHER LIMITATIONS THAT ALLOW PAYMENT FOR AN INITIAL PREVENTIVE PHYSICAL EXAMINATION (IPPE), NOT LATER THAN 12 MONTHS AFTER THE DATE THE INDIVIDUAL'S FIRST COVERAGE PERIOD BEGINS UNDER MEDICARE PART B.
BETOS	M1A – Office visits - new
TOS Code(s)	1 – Medical care
Added Date	1/1/2009
Status Code	Active Code
Global Days	XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC)	0 - Physician Service Code
Multiple Procedures (51)	0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50)	0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62)	0 - Co-surgeons not permitted for this procedure.
Team Surgery (66)	0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Clinic or Emergency Department Visit
MUE	1
MUE	Not applicable/unspecified.
OTS Orthotic	No
CCS Clinical Classification	227 - Other diagnostic procedures (interview, evaluation, consultation)

25	Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service: it may be necessary to indicate that on the day a procedure or service identified by a cpt code was performed, the patient's condition required a significant, separately identifiable e/m service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. a significant, separately identifiable e/m service is defined or substantiated by documentation that satisfies the relevant criteria for the respective e/m service to be reported (see evaluation and management services guidelines for instructions on determining level of e/m service). the e/m service may be prompted by the symptom or condition for which the procedure and/or service was provided. as such, different diagnoses are not required for reporting of the e/m services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of e/m service. note: this modifier is not used to report an e/m service that resulted in a decision to perform surgery. see modifier 57 for significant, separately identifiable non-e/m services, see modifier 59.
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
X1	Continuous/broad services: for reporting services by clinicians, who provide the principal care for a patient, with no planned endpoint of the relationship; services in this category represent comprehensive care, dealing with the entire scope of patient problems, either directly or in a care coordination role; reporting clinician service examples include, but are not limited to: primary care, and clinicians providing comprehensive care to patients in addition to specialty care
GC	This service has been performed in part by a resident under the direction of a teaching physician
GA	Waiver of liability statement issued as required by payer policy, individual case
AQ	Physician providing a service in an unlisted health professional shortage area (hpsa)
59	Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
GE	This service has been performed by a resident without the presence of a teaching physician under the primary care exception
52	Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
GZ	Item or service expected to be denied as not reasonable and necessary
GY	Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
CR	Catastrophe/disaster related
95	Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
PO	Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
32	Mandated services: services related to mandated consultation and/or related services (eg, third party payer, governmental, legislative or regulatory requirement) may be identified by adding modifier 32 to the basic procedure.
SA	Nurse practitioner rendering service in collaboration with a physician
GW	Service not related to the hospice patient's terminal condition
XU	Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
23	Unusual anesthesia: occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. this circumstance may be reported by adding modifier 23 to the procedure code of the basic service.
24	Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period: the physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. this circumstance may be reported by adding modifier 24 to the appropriate level of e/m service.
27	Multiple outpatient hospital e/m encounters on the same date: for hospital outpatient reporting purposes, utilization of hospital resources related to separate and distinct e/m encounters performed in multiple outpatient hospital settings on the same date may be reported by adding modifier 27 to each appropriate level outpatient and/or emergency department e/m code(s). this modifier provides a means of reporting circumstances involving evaluation and management services provided by physician(s) in more than one (multiple) outpatient hospital setting(s) (eg, hospital emergency department, clinic). note: this modifier is not to be used for physician reporting of multiple e/m services performed by the same physician on the same date. for physician reporting of all outpatient evaluation and management services provided by the same physician on the same date and performed in multiple outpatient setting(s) (eg, hospital emergency department, clinic), see evaluation and management, emergency department, or preventive medicine services codes.
33	Preventive services: when the primary purpose of the service is the delivery of an evidence based service in accordance with a us preventive services task force a or b rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. for separately reported services specifically identified as preventive, the modifier should not be used.
51	Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
57	Decision for surgery: an evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of e/m service.
79	Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
93	Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system : synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.
AG	Primary physician
AI	Principal physician of record
AM	Physician, team member service
AR	Physician provider services in a physician scarcity area
CA	Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission
CG	Policy criteria applied
CS	Cost-sharing waived for specified covid-19 testing-related services that result in and order for or administration of a covid-19 test and/or used for cost-sharing waived preventive services furnished via telehealth in rural health clinics and federally qualified health centers during the covid-19 public health emergency
E3	Upper right, eyelid
E4	Lower right, eyelid
FP	Service provided as part of family planning program
FS	Split (or shared) evaluation and management visit
GF	Non-physician (e.g. nurse practitioner (np), certified registered nurse anesthetist (crna), certified registered nurse (crn), clinical nurse specialist (cns), physician assistant (pa)) services in a critical access hospital
GQ	Via asynchronous telecommunications system
GT	Via interactive audio and video telecommunication systems
GV	Attending physician not employed or paid under arrangement by the patient's hospice provider
GX	Notice of liability issued, voluntary under payer policy
HL	Intern
HP	Doctoral level
JK	One month supply or less of drug or biological
JZ	Zero drug amount discarded/not administered to any patient
KB	Beneficiary requested upgrade for abn, more than 4 modifiers identified on claim
KV	Dmepos item subject to dmepos competitive bidding program that is furnished as part of a professional service
KX	Requirements specified in the medical policy have been met
NB	Nebulizer system, any type, fda-cleared for use with specific drug
PB	Surgical or other invasive procedure on wrong patient
PD	Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
PN	Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital
Q1	Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q3	Live kidney donor surgery and related services
Q5	Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
Q6	Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
QJ	Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b)
QW	Clia waived test
TG	Complex/high tech level of care
TK	Extra patient or passenger, non-ambulance
TU	Special payment rate, overtime
U7	Medicaid level of care 7, as defined by each state
UD	Medicaid level of care 13, as defined by each state
XE	Separate encounter, a service that is distinct because it occurred during a separate encounter
XS	Separate structure, a service that is distinct because it was performed on a separate organ/structure