What is the Medicare reimbursement rate for CPT code 99205?

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The national baseline Medicare reimbursement rate for CPT code 99205 in 2026 is $236.81 for non-facility settings (such as an ordinary office) and $160.32 for facility settings (such as a hospital).

Reimbursement Breakdown

  • Non-Facility Rate (Office): ~$236.81
  • Facility Rate (Hospital/Outpatient): ~$160.32
  • Geographic Adjustments: Actual payout amounts change based on your local CMS Physician Fee Schedule lookup tool and regional Geographic Practice Cost Indices (GPCI).
  • Non-Physician Practitioners: Nurse practitioners and physician assistants are typically reimbursed at 85% of the physician fee schedule rate.

Core Requirements for 99205

  • Patient Status: New patient (no professional services from the same physician or same-specialty group within the past 3 years).
  • Medical Decision Making (MDM): High-level MDM (high risk of complications, extensive data review, and severe problem severity).
  • Time Alternative: Total time of 60 minutes or more personally spent by the provider on the date of the encounter.

What are the Medicare reimbursement rates for 2026?

The 2026 Medicare Physician Fee Schedule sets the conversion factor at $33.57 for qualifying Advanced Alternative Payment Model (APM) participants and $33.40 for all other providers.

2026 Conversion Factors

  • Advanced APM Participants: $33.57 (a 3.77% increase from 2025).
  • Non-APM Participants: $33.40 (a 3.26% increase from 2025).
  • Legislative Boost: Includes a 2.5% increase provided under federal legislation.

Key Policy Changes

  • Office vs. Facility Adjustments: CMS increased non-facility practice expense values while reducing facility values, resulting in higher reimbursement for office-based care and cuts for hospital-outpatient or ambulatory surgical center settings.
  • Efficiency Adjustments: A 2.5% productivity reduction applies to select non-time-based diagnostic, procedural, and surgical codes that benefit from standardized workflows.
  • Telehealth and Behavioral Health: Expanded flexibilities continue, including virtual direct supervision and broadened codes for mental health and remote devices.

You can look up specific billing codes and locality adjustments using the PayerPrice Medicare Fee Schedule Lookup or read official policy details from the CMS Physician Fee Schedule.

What is the cost of CPT code 99205?

The national average Medicare reimbursement rate for CPT code 99205 is $236.81, while out-of-pocket costs without insurance typically range from $200 to $375 after cash-pay discounts (with average billed charges around $534).

What CPT Code 99205 Means

  • Definition: An office or outpatient visit for the evaluation and management (E/M) of a new patient.
  • Time Requirement: Takes a total of 60 to 74 minutes of provider time on the date of the encounter.
  • Complexity: Requires a high level of medical decision-making (such as managing multiple complex diagnoses or new prescription drugs).

Cost Breakdown by Payer Type

  • Medicare: $236.81 (national non-facility rate).
  • Commercial Insurance Averages: Generally range between $220 and $270 on average, though contracted rates vary widely by region and medical specialty.
  • Without Insurance: Billed charges can exceed $500, but many clinics reduce the price to $200–$375 if paid in cash.

What are the billing guidelines for CPT code 99205?

To bill CPT code 99205, the encounter must meet either high-complexity Medical Decision Making (MDM) or a minimum of 60 to 74 total minutes of provider time on the date of service.

You can review detailed criteria and definitions through the AAPC Codify Reference.

Core Billing Criteria

  • Patient Status: Reserved for a new patient—defined as someone who has not received any professional services from the billing provider or another physician of the same specialty in the same group within the past three years.
  • Medically Appropriate History and Exam: Must still perform and document a clinically relevant history and physical examination, though selection is no longer driven by the old "key components" count.

Qualification Pathways

You may select CPT 99205 using one of two methods:

  1. High-Complexity Medical Decision Making (MDM): Must meet at least 2 out of 3 elements:
    • Problems: Extensive number or severity of diagnoses/management options (e.g., severe acute threat to life, acute or multi-system failure).
    • Data: Extensive amount or complexity of data reviewed and analyzed (independent historian reports, extensive test interpretations).
    • Risk: High risk of significant complications, morbidity, or mortality from additional diagnostic testing or treatment.
  2. Time-Based Coding:
    • Requires 60 to 74 total minutes spent by the provider on the date of the encounter.
    • Includes both face-to-face and non-face-to-face time (such as reviewing labs, chart review, counseling, and coordinating care) performed personally by the clinician.
    • If the encounter exceeds 74 minutes, you transition into prolonged service codes (such as add-on code +99417 or Medicare-specific G2212).

Documentation and Modifiers

  • Documentation: Must articulate a clear clinical narrative showing medical necessity and the reasoning behind diagnoses or management choices, rather than a generic checklist.
  • Common Modifiers:
    • 25 (Significant, separately identifiable Evaluation and Management service by the same physician on the same day as a procedure)
    • 95 or place-of-service indicators for telehealth visits

What is the RVU rate for CPT code 99205?

For CPT code 99205 (new patient office or other outpatient visit, high complexity, 60–74 minutes), the total non-facility Relative Value Unit (RVU) is 7.09, with an estimated national Medicare payment of $236.81.

RVU Breakdown (Non-Facility / Office Setting)

  • Work RVU (wRVU): 3.50
  • Practice Expense (PE) RVU: ~3.33 (Total non-facility PE and Malpractice make up the remaining balance)
  • Malpractice (MP) RVU: ~0.26
  • Total Non-Facility RVU: 7.09
  • Estimated National Payment: $236.81 (based on the 2026 CMS conversion factor of $33.4009)

(Note: In a facility setting like a hospital outpatient department, the total RVU and payment are lower—approximately 4.80 total RVUs and $160.32—because the facility absorbs the overhead costs).

You can look up specific geographic adjustments using the FastRVU RVU Lookup Table.

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9 related questions found

What are the current Medicare reimbursement rates by CPT code?

You can look up current Medicare reimbursement rates by CPT code using the official PFS Look-up Tool Overview provided by the Centers for Medicare & Medicaid Services (CMS).

How Medicare Rates Are Determined

  • Relative Value Units (RVUs): Each CPT code has assigned RVUs for physician work, practice expense, and malpractice.
  • Geographic Adjustment: RVUs are multiplied by Geographic Practice Cost Indices (GPCIs) based on your specific payment locality.
  • Conversion Factor (CF): The adjusted total is multiplied by the annual conversion factor (around $33.40 to $33.57 depending on Alternative Payment Model participation).
  • Facility vs. Non-Facility: Rates vary depending on whether the service is performed in an office (non-facility) or a hospital/facility setting.
  • Standard Split: Original Medicare generally reimburses 80% of the approved amount, leaving the remaining 20% to coinsurance or secondary insurance.

You can also check estimated patient costs and facility pricing via the Procedure Price Lookup for Outpatient Services on Medicare.gov.

How to look up Medicare reimbursement rates?

You can look up official payment rates using the CMS Physician Fee Schedule Search tool.

How to Use the Lookup Tool

  • Select the Year: Choose the specific calendar year for the services provided.
  • Enter the Code: Input your specific CPT or HCPCS billing code (or a range of codes).
  • Choose Modifiers: Select the relevant modifiers or choose "all" if none apply.
  • Set Location: Pick your specific Medicare Administrative Contractor (MAC) and local payment locality so the tool adjusts rates with the correct Geographic Practice Cost Index (GPCI).

Alternative Methods

  • Outpatient Procedures: Use the Medicare Procedure Price Lookup to find national average costs for services in ambulatory surgical centers and hospital outpatient departments.
  • Contact your MAC: Reach out directly to your regional Medicare Administrative Contractor to download localized fee schedule files (PDF, text, or Excel).

How much does Medicare pay for 99205?

Under the 2026 CMS Medicare Physician Fee Schedule, Medicare pays a national average base rate of $236.81 for CPT code 99205 (a Level 5 evaluation and management visit for a new patient) when performed in a non-facility (office) setting.

The exact payment amount depends on two primary factors:

1. The Setting (Site of Service)

Medicare applies different rates depending on where the appointment takes place:

  • Non-Facility Rate (Private Office or Freestanding Clinic): Approximately $236.81.
  • Facility Rate (Hospital Outpatient Dept. or Emergency Room): Approximately $160.32. (Note: In a facility setting, the hospital typically bills an additional, separate facility fee).

2. Provider Type & Geographic Location

  • Advanced APM Status: For the first time, Medicare utilizes dual conversion factors. Clinicians who are qualifying participants in an Advanced Alternative Payment Model (APM) receive a slightly higher conversion factor ($33.57) than non-qualifying practitioners ($33.40), making their base reimbursement roughly $222.78 to $223.90 before geographic modifiers.
  • Geographic Adjustments: The exact reimbursement is adjusted locally based on the Geographic Practice Cost Index (GPCI). Providers in areas with a higher cost of living or doing business receive a higher payout, while rural or lower-cost regions receive less.

Tip: To see the exact dollar amount for a specific zip code or Mac jurisdiction, use the official CMS Physician Fee Schedule Lookup Tool.

How often can a CPT code 99205 be billed?

You can bill CPT code 99205 once per day per new patient, provided the clinical encounter meets the strict criteria for high-complexity medical decision-making or 60–74 total minutes of provider time on that single date of service.

Billing Frequency Rules

  • Per Encounter: It is tied to a distinct, single date of service for a new patient.
  • New Patient Status Only: A "new patient" is defined as someone who has not received any professional services from the physician or exact same specialty group practice within the past 3 years.
  • No Lifetime Cap: There is no universal limit on how many times you can bill 99205 across different new patients, but billing it frequently or repeatedly for the same patient or without proper documentation will trigger payer audits.

What is the time requirement for CPT code 99205 in 2026?

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

Key Details on Time-Based Billing for 99205

  • Total Provider Time: Includes both face-to-face time with the patient and non-face-to-face work done on the same calendar date (such as reviewing medical records, writing notes, and ordering tests).
  • Prolonged Services: If the total time reaches 75 minutes or more, you can report prolonged services using add-on code 99417 (for commercial payers) or G2212 (for Medicare, once the threshold reaches 89+ minutes).
  • Alternative Pathway: CPT 99205 can also be selected based on a high level of Medical Decision Making (MDM) regardless of total time.