G0402 — Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment

What the market charges

Across 747 negotiated rates, the middle 80% fall between $80 and $407, with a median of $174.

What Medicare pays

Medicare allowed an average of $158 for this code, across 217,525 services billed by 13,481 providers. At the median, the market charges 1.1 times what Medicare pays for this code.

Where this is billed, and what it costs there

The states billing G0402 most, by Medicare service volume, each compared against the national average of $158. Each links to the providers Mishe lists there.

• Florida — 1,058 providers billed it, Medicare allowed $158 — level with the national average
• Texas — 1,013 providers billed it, Medicare allowed $156 — 1% below the national average
• Illinois — 832 providers billed it, Medicare allowed $164 — 4% above the national average
• Pennsylvania — 775 providers billed it, Medicare allowed $156 — 1% below the national average
• California — 695 providers billed it, Medicare allowed $173 — 9% above the national average
• New Jersey — 686 providers billed it, Medicare allowed $172 — 9% above the national average
• New York — 641 providers billed it, Medicare allowed $180 — 14% above the national average
• Virginia — 640 providers billed it, Medicare allowed $157 — 1% below the national average

Claim-editing rules

These are National Correct Coding Initiative procedure-to-procedure edits — the rules a payer applies when deciding whether two codes billed together are both payable.

Codes this one absorbs

Billed together, G0402 is the payable code and these are not separately payable. 38 pairs in total.

• 36591 — no modifier can override this edit
• 36592 — no modifier can override this edit
• 92002 — a modifier may allow both to be paid
• 92004 — a modifier may allow both to be paid
• 92012 — a modifier may allow both to be paid
• 92014 — a modifier may allow both to be paid
• 93000 — a modifier may allow both to be paid
• 93005 — a modifier may allow both to be paid
• 93010 — a modifier may allow both to be paid
• 93040 — a modifier may allow both to be paid
• 93041 — a modifier may allow both to be paid
• 93042 — a modifier may allow both to be paid

Other codes

• J2777 — Injection, faricimab-svoa, 0.1 mg
• J0897 — Injection, denosumab, 1 mg
• J9271 — Injection, pembrolizumab, 1 mg
• J0129 — Injection, abatacept, 10 mg (code may be used for medicare when drug administered under the direct supervision of a physician, not for use when drug is self administered)
• G0008 — Administration of influenza virus vaccine
• G0439 — Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit
• J9144 — Injection, daratumumab, 10 mg and hyaluronidase-fihj
• J9299 — Injection, nivolumab, 1 mg
• J1745 — Injection, infliximab, excludes biosimilar, 10 mg
• J2357 — Injection, omalizumab, 5 mg

Deploy this for your team

Every figure on this page came from published payer and Medicare data, assembled by Mishe. The same pricing, claim-editing and care-pathway intelligence runs underneath the plans Mishe operates.

• Contact Mishe to learn how to deploy these resources for your team
• Guides to direct-pay healthcare
• Cash prices by procedure
• Find a provider by state

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