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99205

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🩺CPT 99205 - New Patient Office Visit, Level 5

CPT Code: 99205
Status: New Patient
Complexity Level: High Category: Office/Outpatient E/M Services
Typical Time: 60-74 minutes
Effective Date: January 1, 2021 (Current Definition)

📋Short Description

Office or outpatient visit for evaluation and management of a new patient requiring high complexity medical decision making OR 60-74 minutes of total time on the date of encounter.

Full Description

CPT 99205 is the highest-level evaluation and management (E/M) code for new patient office or outpatient visits. This code represents comprehensive services for patients with complex, high-risk medical conditions requiring extensive provider work.

Official Descriptor:
“Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making”.

Code Selection Criteria (2021+ Guidelines)

Select 99205 based on EITHER:

  1. Medical Decision Making (MDM): High complexity, OR

  2. Total Time: 60-74 minutes on date of encounter

Tip

Note: Time and MDM are independent - meet either criterion to bill 99205.

RVU Information (2026)

ComponentValue
Work RVU (wRVU)3.17
Total RVU6.67
Medicare Reimbursement (National Avg)223.90

Tip

Reimbursement Note: Actual payment varies by geographic locality (GPCI adjustment), payer contracts, and APM participation .

Time Requirements

Time RangeCode Selection
60-74 minutes99205
≥75 minutes99205 + G2212 (prolonged services add-on)

What Counts as “Total Time” on Date of Encounter:

  • Face-to-face and non-face-to-face time spent by provider/clinical staff

  • Preparing to see patient (reviewing records)

  • Obtaining and documenting history/exam

  • Counseling and educating patient/family

  • Ordering tests/medications

  • Documenting in medical record

  • Communicating with other providers

  • Care coordination

What Does NOT Count:

  • Time spent on services separately reported

  • Staff time when provider is not personally involved

Medical Decision Making (MDM) - High Complexity

To meet High Complexity MDM, must satisfy requirements of 2 out of 3 elements:

1. Number and Complexity of Problems Addressed

High = 1 or more of the following:

  • 1 acute or chronic illness that poses threat to life or bodily function

  • Acute illness with severe exacerbation, progression, or side effects of treatment

  • Chronic illness with severe exacerbation, progression, or side effects of treatment

2. Amount/Complexity of Data Reviewed and Analyzed

High = Meet requirements of at least 2 of 3 categories:

  • Category 1: Extensive review of tests, documents, or independent historian(s)

  • Category 2: Independent interpretation of tests

  • Category 3: Discussion of management or test interpretation with external provider

3. Risk of Complications and/or Morbidity or Mortality

High risk includes:

  • Drug therapy requiring intensive monitoring for toxicity

  • Decision regarding emergency major surgery

  • Decision regarding hospitalization

  • Decision not to resuscitate or de-escalate care due to poor prognosis

HCC Information

Direct HCC Assignment: E/M codes like 99205 do not have HCC assignments themselves.

HCC Relationship: The ICD-10-CM diagnosis codes billed with 99205 may map to Hierarchical Condition Categories (HCCs) that affect risk adjustment and reimbursement in Medicare Advantage, ACO, and value-based care models.

Common HCC Diagnoses Associated with High-Complexity Visits:

  • Diabetes with complications (HCC 19)

  • Heart failure (HCC 85)

  • COPD (HCC 111)

  • Acute kidney injury/CKD (HCC 135-137)

  • Major depression (HCC 59)

  • Cancer diagnoses (various HCC categories)

  • Stroke/TIA (HCC 99-103)

Coding Tip: Ensure thorough documentation of all chronic conditions, complications, and severity to support both the 99205 level and appropriate HCC capture.

Clinical Examples

Example 1: Multiple Chronic Conditions

Patient: 68-year-old new patient with uncontrolled Type 2 diabetes with diabetic nephropathy, Stage 3 CKD, hypertension, and recent chest pain requiring extensive workup.

Why 99205: High MDM due to chronic illness with progression (CKD + diabetic complications), extensive data review (labs, EKG, imaging), and high risk (cardiac evaluation, medication adjustments for renal function).

Sample ICD-10 Codes:

  • E11.21 - Type 2 diabetes with diabetic nephropathy

  • N18.3- - Chronic kidney disease, stage 3

  • I10 - Essential hypertension

  • R07.9 - Chest pain, unspecified

Example 2: Acute Severe Condition

Patient: 45-year-old new patient presenting with severe major depressive disorder with suicidal ideation, requiring crisis assessment and coordination of urgent psychiatric care.

Why 99205: High MDM due to acute condition posing threat to life (suicidal ideation), extensive discussion with psychiatric providers, high-risk decision making regarding hospitalization vs. intensive outpatient treatment.

Sample ICD-10 Codes:

  • F32.2 - Major depressive disorder, single episode, severe without psychotic features

  • R45.851 - Suicidal ideations

Example 3: New Cancer Diagnosis

Patient: 62-year-old new patient referred for recently diagnosed metastatic lung cancer requiring treatment planning, symptom management, and coordination with oncology.

Why 99205: High MDM due to acute illness posing threat to life, extensive review of pathology/imaging, complex treatment planning, and high-risk medication decisions.

Sample ICD-10 Codes:

  • C34.91 - Malignant neoplasm of unspecified part of right bronchus or lung

  • C79.51 - Secondary malignant neoplasm of bone

  • R05.9 - Cough, unspecified

Common ICD-10-CM Pairings with 99205

ConditionICD-10-CMNotes
Uncontrolled Type 2 DM with complicationsE11.65, E11.21, E11.9Document specific manifestations
Acute exacerbation of COPDJ44.1High-risk respiratory condition
Acute kidney injuryN17.9Acute condition requiring urgent eval
Heart failure, acuteI50.9, I50.21, I50.23Specify type (systolic/diastolic)
Major depression, severeF32.2, F33.2With or without suicidal ideation
New cancer diagnosisC34.90, C50.911, etc.Site-specific codes
Chest pain, cardiac evalR07.9, R07.2Rule out MI
CVA/TIAI63.9, G45.9Acute neurological event

Documentation Requirements

Essential Elements for 99205

✅ Chief Complaint: Clearly stated reason for visit
✅ Medical Decision Making: Document 2 of 3 MDM elements at high complexity level
✅ Time (if using time): Total time spent on date of encounter (document in minutes)
✅ Assessment/Plan: Clear documentation of diagnoses, complexity, and management plan
✅ Medical Necessity: Condition must support high-level visit

Documentation Best Practices

  • Be specific about severity, progression, complications

  • Document discussions with other providers and care coordination efforts

  • List all data reviewed: Labs, imaging, records from other facilities, independent historian

  • Describe risk factors: Document why condition poses significant threat or requires intensive monitoring

  • If using time: State total time clearly (“Total time: 65 minutes”)

  • Align complexity: Your documentation should clearly reflect high-complexity MDM or 60+ minutes

Common Documentation Pitfalls

⚠️ Insufficient problem complexity documented
⚠️ Vague assessment without clear severity/risk
⚠️ Missing data review documentation
⚠️ Time not documented when needed
⚠️ Cookie-cutter templates that don’t reflect actual complexity

Coding Tips & Pearls

💡 New vs. Established: Patient must be NEW (not seen by provider or same specialty in same practice within past 3 years)

💡 Prolonged Services: For visits ≥75 minutes, add G2212 for each additional 15 minutes beyond 60

💡 Medical Necessity: 99205 should be reserved for truly complex patients whose conditions pose immediate threat or require intensive management

💡 Audit Risk: 99205 is frequently audited - ensure documentation clearly supports level billed

💡 MDM vs. Time: Choose the method that best reflects your service. You don’t need to document both (though documenting both provides backup)

💡 Preventive vs. Problem-Oriented: 99205 is for problem-oriented visits, NOT routine preventive care. For preventive, use 99385-99387 instead

CPTDescriptionwRVUTime/MDM
99202New patient, Level 20.9315-29 min / Straightforward MDM
99203New patient, Level 31.6030-44 min / Low MDM
99204New patient, Level 42.6045-59 min / Moderate MDM
99205New patient, Level 53.1760-74 min / High MDM
G2212Prolonged office E/M (add-on)0.61Per additional 15 min (use with 99205/99215)
99215Established patient, Level 52.8040-54 min / High MDM

Modifier Considerations

Common modifiers that may apply to 99205:

ModifierDescriptionWhen to Use
-25Significant, separately identifiable E/ME/M on same day as procedure
-57Decision for surgeryE/M led to decision for major surgery (≥90 day global)
-AIPrincipal physician of recordFor inpatient consults in some payers
CPT_99253_TemplateTelehealth (synchronous)When visit conducted via telehealth

References & Resources

  • CPT® Professional Edition - American Medical Association

  • CMS Medicare Physician Fee Schedule - 2026 Final Rule

  • E/M Services Guidelines - CMS MLN Booklet

  • AAFP E/M Coding Resources - Time and MDM Tables

  • Medicare Claims Processing Manual - Chapter 12, Section 30.6

Quick Reference Card

CPT 99205 - New Patient Level 5 
━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ 
✓ New patient only 
✓ High MDM OR 60-74 minutes 
✓ wRVU: 3.17 | Total RVU: 6.67 
✓ ~$223 Medicare reimbursement 
✓ Threat to life/bodily function 
✓ Extensive data review required 
✓ High-risk decision making 
✓ Add G2212 if ≥75 minutes`

Last Updated: February 9, 2026
Created for clinical reference - verify current guidelines and local payer policies

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