What constitutes a 99205 visit?

CPT code 99205 represents an outpatient or office evaluation and management (E/M) visit for a new patient that requires a medically appropriate history and/or examination and a high level of medical decision making (MDM), or a minimum of 60 to 74 minutes of total time spent on the date of the encounter.

Core Requirements

To qualify for 99205 via Medical Decision Making, you must meet or exceed at least two of the following three elements:

• Number and Complexity of Problems: One or more chronic illnesses with severe exacerbation, progression, or side effects; or an acute/chronic illness/injury that poses an immediate threat to life or bodily function (e.g., severe respiratory distress, acute myocardial infarction, or major depression with active suicidal ideation).
• Amount and Complexity of Data: Extensive data to review and analyze, such as independent test interpretations, extensive external records review, or discussions of management with an external healthcare professional.
• Risk of Complications/Morbidity: High risk of morbidity from additional diagnostic testing or treatment, such as decisions regarding emergency major surgery, hospitalization, or intensive drug-therapy monitoring for toxicity.

Time-Based Billing Alternative

• Total Duration: 60 to 74 minutes of total provider time (face-to-face and non-face-to-face) spent on the date of the encounter.
• Prolonged Services: If the total time reaches 75 minutes or longer, additional prolonged service codes (such as +99417) may be used.

Patient Status Criteria

• New Patient Definition: A patient who has not received any professional services from the billing provider—or another provider of the exact same specialty in the same group practice—within the past 3 years.

CPT code 99205 qualifies for a new patient outpatient or office visit that requires high-complexity medical decision-making or a total provider time of 60 to 74 minutes on the date of the encounter.

Patient Status Requirements

• New Patient: The patient must not have received any professional services from the provider (or another provider of the exact same specialty in the same practice) within the past three years.

Pathway 1: High-Complexity Medical Decision-Making (MDM)

Qualifying via MDM requires meeting at least two out of three elements:

• Problems: Managing severe, progressive, or life-threatening conditions (e.g., severe exacerbations or acute threats to life/function).
• Data: Analyzing an extensive amount of data, including independent test interpretations or extensive external records.
• Risk: High risk of morbidity from treatment or testing, or decisions regarding emergency surgery/hospitalization.

Pathway 2: Time-Based Coding

• Total Time: Spending 60 to 74 minutes of combined face-to-face and non-face-to-face provider time on the encounter date.
• Activities: Encompasses chart review, exams, counseling, ordering tests, and care coordination.
• Prolonged Services: Times of 75 minutes or more require a prolonged services add-on code instead.

The time threshold for CPT code 99205 is 60 to 74 total minutes of total provider time spent on the date of the encounter.

Time-Based Billing Details

• Base Code Requirement: 60 minutes must be met or exceeded to report 99205 via time, covering a range from 60 up to 74 minutes.
• Prolonged Services Thresholds:
  • For non-Medicare/commercial payers using American Medical Association (AMA) guidelines, prolonged services (code 99417) begin at 75 minutes or more (15 minutes beyond the 60–74 minute range).
  • For Medicare claims, HCPCS code G2212 for prolonged service starts at 89 minutes total time (meaning 99205 covers up to 88 minutes for Medicare before the first prolonged increment kicks in at 89–103 minutes).

Alternative Qualification

• Medical Decision Making (MDM): Time-based coding is optional if the encounter qualifies via high-complexity MDM. You can code 99205 based on high-complexity MDM (meeting at least two of the three MDM elements) regardless of whether the total duration falls short of 60 minutes, though time is an independent pathway.

CPT code 99214 requires an office or outpatient visit for an established patient that involves moderate-complexity medical decision-making (MDM) or a total provider time of 30 to 39 minutes on the date of the encounter.

Patient Eligibility

• The patient must be an established patient (seen by the same physician or same-specialty group within the past three years).

Option 1: Medical Decision-Making (MDM) Criteria

To qualify via MDM, at least two of the three following elements must reach a moderate level:

1. Number and Complexity of Problems Addressed: Must meet at least one, such as:
   • Two or more stable chronic illnesses.
   • One or more chronic illnesses with exacerbation, progression, or side effects of treatment.
   • One undiagnosed new problem with an uncertain prognosis.
   • One acute illness with systemic symptoms.
2. Amount and/or Complexity of Data Reviewed and Analyzed: Must meet moderate criteria (earning points through reviewing or ordering tests, analyzing external notes, or using an independent historian).
3. Risk of Complications and/or Morbidity of Patient Management: Must involve moderate risk, such as prescription drug management or decision-making regarding minor surgery with risk factors. (Note: A simple prescription refill alone for a single stable condition typically counts as moderate risk, but without a second moderate MDM element, the visit defaults to code 99213).

Option 2: Time-Based Criteria

• The provider spends 30 to 39 total minutes of face-to-face and non-face-to-face work on the date of the service (including chart review, ordering tests, and documenting in the EHR).

A level 4 new patient office visit (CPT code 99204) requires spending 45 to 59 minutes of total time on the date of the encounter, or reaching a moderate level of medical decision-making (MDM).

A "new patient" is someone who has received no professional services face-to-face from the provider—or another provider of the exact same specialty and subspecialty in the same group—within the past three years.

Medical Decision-Making (MDM) Criteria

To qualify via MDM, your documentation must meet or exceed a moderate level in at least two of the following three elements:

• Problems Addressed: Reaching a moderate level, such as:
  • One or more chronic illnesses with moderate exacerbation, progression, or side effects of treatment.
  • Two or more stable chronic illnesses.
  • One acute illness with systemic symptoms.
  • One acute, complicated injury.
• Data Reviewed and Analyzed: Reaching a moderate level, which requires meeting a combination of categories such as:
  • Reviewing prior external notes from a unique source.
  • Reviewing the results of each unique test.
  • Ordering or reviewing a combination of tests or documents that add up to a moderate category (e.g., ordering/reviewing three distinct tests or interpreting an independent visualization like an X-ray or ECG).
• Risk of Complications and/or Morbidity/Mortality: Reaching a moderate level of risk associated with the patient’s management, such as:
  • Prescription drug management (e.g., initiating, adjusting, or monitoring a prescription medication).
  • Decision regarding minor surgery with identified patient or procedure risk factors.

Time-Based Criteria

If you choose to code by time instead of MDM, the service requires 45 to 59 minutes of total time spent on the exact date of the encounter. This encompasses pre-, intra-, and post-encounter work—such as reviewing prior records before the visit, face-to-face communication, and documenting the electronic health record or coordinating care later that same day.