When can you bill 99205?

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You can bill CPT Code 99205 for an outpatient or office evaluation and management (E/M) visit for a new patient that requires a medically appropriate history and exam alongside a high level of medical decision-making (MDM), or when spending 60 to 74 total minutes of provider time on the encounter date.

Core Billing Criteria

You can select 99205 based on either Medical Decision-Making or Total Time:

  • Patient Status: Must be a new patient (someone who has not received any professional services from the provider—or another provider of the exact same specialty in the same group—within the past 3 years).
  • Medical Decision-Making (High Complexity):

What are the billing criteria for CPT code 99205?

CPT code 99205 requires a new patient office or outpatient visit with a high level of medical decision-making (MDM) or a minimum of 60 total minutes of provider time on the date of the encounter.

Core Criteria

  • Patient Status: Must be a new patient (no professional services from the provider or same-specialty group in the past three years).
  • History and Exam: Requires a medically appropriate history and/or examination, though comprehensive history/exam checklists are no longer mandatory.
  • Medical Decision-Making (MDM): Requires high-complexity MDM, meeting at least two of the three AMA elements:
    • Number and complexity of problems addressed.
    • Amount and/or complexity of data reviewed and analyzed.
    • Risk of complications and/or morbidity of patient management.
  • Time-Based Billing: Requires a minimum of 60 minutes of total time (face-to-face and non-face-to-face work on the encounter date, such as chart review and documentation). For visits lasting 75 minutes or longer, add prolonged services code 99417.

Key Documentation & Billing Rules

  • Selection Pathway: Choose code selection via either the MDM pathway or the total time pathway—do not double-count or mix requirements.
  • Modifiers: Append Modifier 25 if a separate, distinct evaluation and management service is performed on the same day as a procedure. Use telehealth modifiers (95 or GT) if applicable.
  • Audit Risks: Level 5 codes like 99205 are primary targets for payer and OIG audits; clinical notes must reflect true medical necessity and reasoning rather than generic templates. You can review additional compliance tips via the AAPC Codify Database.

How often can 99205 be billed?

CPT code 99205 can be billed only one time per patient per provider or practice group every three years, as it is strictly designated for a new patient.

Key Billing Frequency Rules

  • New Patient Status: The patient must not have received any professional services from the billing provider—or another physician/provider of the same exact specialty and subspecialty within the same physician group—in the past three years.
  • Per Encounter Limit: You can bill it once for that qualifying initial visit if it meets the criteria of 60–74 minutes of total provider time or a high level of medical decision-making (MDM).
  • Subsequent Visits: Any visits after the initial new patient encounter within that three-year window must be billed using established patient codes (99211–99215), even if the clinical complexity remains high.
  • Audit Triggers: As outlined by ClaimMax RCM, billing code 99205 too frequently or disproportionately compared to your peer group or specialty bell curve will rapidly attract post-payment payer audits or compliance scrutiny.

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.

What's the difference between 99204 and 99205?

The main difference between CPT code 99204 and 99205 is that 99204 involves moderate-complexity medical decision-making or 45 to 59 minutes of total time, while 99205 involves high-complexity decision-making or 60 to 74 minutes of total time for a new patient visit.

Key Comparison Details

  • Patient Status: Both codes apply exclusively to new patients (those who have not received professional services from the physician or same-specialty group within the past three years).
  • CPT 99204 (Level 4):
    • Time: 45 to 59 minutes of total provider time on the date of service.
    • Medical Decision-Making (MDM): Moderate complexity (requires meeting moderate levels in at least two of the three MDM elements: problems addressed, data reviewed, and risk of complications).
    • Typical Scenarios: Multiple chronic conditions with a moderate exacerbation, or a new undiagnosed problem with systemic symptoms.
  • CPT 99205 (Level 5):
    • Time: 60 to 74 minutes of total provider time on the date of service.
    • Medical Decision-Making (MDM): High complexity (requires meeting high levels in at least two of the three MDM elements).
    • Typical Scenarios: Severe exacerbations posing an immediate threat to life or function, newly diagnosed high-stakes conditions like cancer, or complex multi-system management.

As users on Reddit agree, you can code by either total time or MDM, meaning a visit reaching the 60-minute threshold independently supports 99205 even if the clinical decision complexity is lower.

What is a level 5 office / outpatient visit in medical coding? 99215 & 99205 explained.

9 related questions found

How much does 99205 reimburse?

The 2026 Medicare national baseline reimbursement rate for CPT code 99205 (a high-complexity evaluation and management visit for a new patient) is $236.81 for an office/non-facility setting.

However, the exact amount varies significantly based on the type of insurance, the setting where care is delivered, and the geographic location.

Reimbursement Breakdown by Payer and Setting

Payment Type / Insurance2026 Reimbursement Rate
Medicare Non-Facility (Office)~$236.81 (National baseline baseline before geographic adjustment)
Medicare Facility (Hospital Outpatient)~$160.32 (Physician fee only; hospital bills a separate facility fee)
Commercial Payers (e.g., BCBS, Aetna, Cigna)~$230 to $350+ (Typically paid as a negotiated multiplier of Medicare rates, varying highly by provider contract)
MedicaidVaries widely by state (Typically lower than Medicare rates)

Key Factors Affecting Your Payout

  • Geographic Adjustments (GPCI): Medicare rates are adjusted by the geographic practice cost index. In low-cost areas, the rate will drop slightly, whereas high-cost metropolitan areas (e.g., New York or San Francisco) can push the Medicare allowable rate over $260 per encounter.
  • Complexity Add-ons: If the patient requires ongoing longitudinal care for a complex condition, you can often bill the G2211 add-on code alongside 99205 to receive an additional payment (roughly $16+ depending on the year's final rule).
  • Prolonged Services: CPT 99205 covers a time range of 60–74 minutes. If the encounter extends significantly beyond that, you can bill prolonged service codes (CPT 99417 for commercial payers at 75+ minutes or HCPCS G2212 for Medicare at 89+ minutes) for incremental bumps in reimbursement.

To find the exact, contract-specific allowable amount for your practice, use the official CMS Physician Fee Schedule Lookup Tool or refer to your specific private commercial payer contract schedules.

Which CPT codes will be deleted in 2026?

The American Medical Association deleted 84 codes in the 2026 CPT code set update effective January 1, 2026.

Key Deleted Code Families

  • Lower Extremity Revascularization (LER): Long-standing codes 37220 through 37235 were deleted and replaced by new territory-based codes (37254–37299).
  • Hearing Device Services: Legacy codes 92590 through 92595 were deleted and replaced by a new 12-code pathway (92628–92642).
  • Urology / Prostate Procedures: Select older codes such as laser coagulation code 52647 and previous prostate biopsy codes were removed or restructured in favor of more specific guidance and approach methods.

Is 99205 covered by Medicare?

Yes, Medicare covers CPT code 99205 when it is medically necessary and provided by an eligible healthcare practitioner.

Service Details

  • Definition: CPT 99205 is a Level 5 Evaluation and Management (E/M) visit for a new patient in an office or outpatient setting.
  • Requirements: The visit requires a high level of medical decision-making or a total time of 60 to 74 minutes spent on the date of the encounter.
  • Coverage Rules: The service must be deemed necessary for diagnosing or treating an illness or injury, and the provider must properly document the high complexity or time.

Cost and Billing

  • Medicare Payment: Under the Medicare Physician Fee Schedule, Medicare reimburses approximately $236.81 for a non-facility (office) setting and around $160.32 for a facility setting, subject to geographic adjustments.
  • Patient Responsibility: After meeting your Part B deductible, you typically pay 20% of the Medicare-approved amount if you have Original Medicare (unless you have supplemental Medigap or secondary insurance coverage).

How much time is CPT 99205?

CPT code 99205 requires 60 to 74 minutes of total time spent on the date of the encounter when using time to select the code.

Total Time Rules

  • Definition: Total time includes both face-to-face and non-face-to-face activities performed by the billing provider on the date of service.
  • Included activities: Reviewing outside medical records or test results before the visit, direct patient interaction/counseling during the visit, ordering prescriptions or tests, coordinating care with other clinicians, and documenting the medical record.
  • Excluded activities: Time spent by clinical staff members who are not the billing provider does not count toward this total.

Alternative Code Selection

  • Code 99205 can also be chosen based on a high level of medical decision-making (MDM) rather than time. You only need to meet either the time threshold or the high MDM threshold, not both.

Prolonged Services

  • If the total encounter time extends to 75 minutes or longer, you can report a prolonged services add-on code (such as CPT +99417 or HCPCS G2212 depending on your payer) in addition to 99205.

What is the difference between CPT code 99205 and 99215?

The primary difference between CPT codes 99205 and 99215 is that 99205 is for new patients, while 99215 is for established patients. Both represent the highest level (Level 5) of outpatient evaluation and management services requiring high-complexity medical decision-making.

Patient Type

  • 99205: For a new patient who has not received any professional services from the provider (or another provider of the exact same specialty in the same group practice) within the past 3 years.
  • 99215: For an established patient who has been seen by the provider or same group/specialty within the past 3 years.

Time Requirements

Both codes can be selected using either medical decision-making (MDM) or total time spent on the date of the encounter.

  • 99205 Time: Requires 60 to 74 minutes of total time.
  • 99215 Time: Requires 40 to 54 minutes of total time.
  • Note: If time is exceeded past these ranges, prolonged service codes may apply.

Medical Decision-Making (MDM)

Both codes require a high level of MDM, meaning you must meet or exceed the high threshold in at least 2 of the following 3 elements:

  • Problems addressed: Multiple chronic illnesses with severe exacerbation, or a single acute/chronic illness posing a severe threat to life or bodily function.
  • Data reviewed: Extensive and complex data to review and analyze.
  • Risk: High risk of complications, morbidity, or mortality from additional diagnostic testing or treatment.