CPT Code 99205: New Patient Office Visit, 60-74 Minutes

CPT code 99205 reports the highest-level office or outpatient E/M visit for a new patient, requiring high medical decision-making. 

It belongs to the E/M category and applies exclusively to patients who have not received professional services from the same physician or same-specialty group within the past three years. 

Providers select 99205 through either high MDM (two of three elements at the high level) or 60+ minutes of qualifying physician time on the date of service.

99205 is the most heavily scrutinized new-patient code because of its reimbursement — roughly $237 per visit under Medicare. 

CMS specifically lists 99205 among codes subject to its new-patient Recovery Audit, and OIG has settled cases involving upcoded 99205 claims and falsified E/M time. 

The two-of-three high-MDM bar is substantially harder to clear than most practices realize — ordinary prescription management is moderate risk, not high, and three Category-1 data items alone do not produce high data.

What does CPT code 99205 cover?

The essential reference facts for 99205 billing.

Detail	CPT 99205
Description	New patient office visit, 60-74 minutes
Category	Evaluation and Management (E/M)
Patient type	New only
MDM level	High
Time	60+ minutes (60-74 base; G2212 starts at 89 min for Medicare)
Common modifiers	25, 57, 95, 93, G2212
Medicare rate	~$236.81 non-facility / ~$160.32 facility (2026)
Commonly compared with	CPT 99204

99205 does not mean “complex-looking new patient.” 

If MDM is the selection method, the encounter must clear the formal high-MDM bar — two of three elements at high — which involves conditions threatening life or bodily function, extensive data across multiple categories, and risk involving hospitalization, emergency surgery, or intensive drug-toxicity monitoring.

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When should you use CPT 99205?

99205 requires both new-patient status and genuinely high clinical complexity — or 60+ minutes of qualifying time.

Use CPT 99205 when

• The patient is genuinely new (no same-specialty/group services in prior three years)
• At least two of three MDM elements reach the high level
• Or the provider spends 60+ qualifying minutes on the date of service
• The visit involves a life- or function-threatening condition, hospitalization decisions, emergency or high-risk major surgery decisions, or intensive drug-toxicity monitoring

When not to use it

• The patient is established — use 99215 for high-MDM established patients
• Only one MDM element reaches high — moderate MDM (99204) may apply
• Prescription management is the sole “high risk” claim — ordinary Rx management is moderate risk, not high
• Three Category-1 data items are the only data — that satisfies Category 1 alone, not the two-category requirement for high data
• The patient has multiple chronic conditions, but none involves severe exacerbation or threat to life/function — 99204 is likely the correct code

How is CPT 99205 selected?

Two independent pathways support 99205. A provider does not need both.

MDM pathway

At least two of these three elements must reach the high level.

MDM element	High threshold for 99205
Problems addressed	1+ chronic illness with severe exacerbation/progression/treatment side effects, or 1 acute/chronic illness posing a threat to life or bodily function
Data reviewed	Must meet 2 of 3 categories — Cat. 1 (combination of 3 qualifying items) PLUS Cat. 2 (independent test interpretation) and/or Cat. 3 (discussion with external physician)
Risk	Intensive drug-toxicity monitoring, emergency major surgery, elective major surgery with identified risk factors, hospitalization decision, or de-escalation/DNR decision

Two critical traps with 99205 MDM. Ordinary prescription management is moderate risk — not high — and does not satisfy the high-risk element. 

Three Category-1 data items (external notes, test reviews, test orders) satisfy only Category 1; high data requires two of the three data categories, meaning you also need either an independent test interpretation or an external-physician discussion.

Time pathway

If 60+ total physician/QHP minutes are spent on the date of service, 99205 is independently supported. 

For Medicare, the base-code interval is 60-74 minutes; G2212 (Medicare’s prolonged-service add-on) first becomes billable at 89 minutes. 

CPT’s own prolonged-service threshold (99417) begins at 75 minutes — a meaningful difference for practices billing non-Medicare payers.

What documentation supports CPT 99205?

For a $237 new-patient code, the documentation bar is the highest in the office/outpatient E/M family.

The note should clearly establish

• Medical necessity for a level-5 encounter
• New-patient status under the three-year/same-specialty rule
• Why the condition constitutes a severe exacerbation or threat to life/bodily function
• Which data categories (not just items) were counted — high data requires two of three categories
• The specific high-risk management decision (hospitalization, emergency surgery, intensive monitoring)

When billing by time, record actual total minutes. Medicare’s prolonged-service add-on (G2212) does not begin until 89 minutes with 99205 — do not use CPT 99417 for Medicare or report G2212 at 75-88 minutes.

How much does CPT 99205 reimburse?

99205 pays the highest rate in the new-patient office E/M family — and carries proportionally higher audit risk.

Payment type	2026 rate
Medicare non-facility (national baseline)	~$236.81
Medicare facility (national baseline)	~$160.32
Commercial payers (median observed)	~$230-$234
Medicaid	Varies by state

Medicare rates from CMS 2026 PFS national baselines (7.09 total RVU non-facility × ~$33.40 conversion factor).

The $77 gap between non-facility and facility rates reflects overhead allocation. Geographic GPCI adjustments can push the actual non-facility allowable above $260 in high-cost localities. 

CMS has proposed a ~1.68% 2027 conversion factor reduction that would lower 99205 payments if finalized.

Which modifiers apply to CPT 99205?

The modifier landscape for 99205 includes the standard E/M set plus the Medicare prolonged-service distinction.

Modifier	When it applies
25	Significant, separately identifiable E/M on the same day as a procedure — new-patient status alone does not justify it
57	E/M resulting in the decision for major surgery (90-day global)
95	Synchronous audio-video telehealth
93	Audio-only telehealth (qualifying services through 12/31/2027)
G2212	Medicare prolonged E/M — first unit at 89 total minutes with 99205

For Medicare telehealth, POS 10 (patient home) pays the non-facility rate (~$236.81) while POS 02 (other location) pays the facility rate (~$160.32). Do not use CPT 99417 for Medicare — Medicare uses G2212 at different thresholds.

CPT 99205 vs. 99204 — which one fits?

Both cover new patients. The distinction between 99204 and 99205 is the difference between moderate and high complexity.

Feature	CPT 99205	CPT 99204
Patient type	New	New
MDM level	High	Moderate
Time	60+ minutes	45-59 minutes
Typical use	Life-threatening condition, severe exacerbation, hospitalization, emergency surgery	2+ stable chronic conditions, chronic exacerbation, uncertain diagnosis
Medicare rate (2026)	~$236.81	~$177.36
Work RVU	3.50	2.60

Choose 99205 when at least two MDM elements reach high, or qualifying time reaches 60+ minutes.

Choose 99204 when two elements reach moderate but not high. 

Two stable chronic illnesses plus prescription management produces moderate problems and moderate risk — supporting 99204, not 99205. 

Upgrading to 99205 requires the condition to involve severe exacerbation or threat to life/function, plus a second high element.

What billing errors should you avoid with CPT 99205?

Five errors drive most 99205 denials and audit exposure.

1. Billing 99205 for an established patient 

CMS’s Recovery Audit specifically targets incorrect new-patient coding. Verify the three-year/same-specialty history before selecting any new-patient code.

2. Assuming one high MDM element is enough 

99205 requires two of three elements at high. A life-threatening condition alone (high problems) does not make the visit 99205 if data and risk remain moderate.

3. Treating prescription management as “high risk” 

Ordinary prescription drug management is an AMA example of moderate risk. High risk requires intensive toxicity monitoring, hospitalization decisions, emergency major surgery, or qualifying elective major surgery with identified risk factors.

4. Overcounting high-level data 

Three Category-1 items (external notes, test reviews, test orders) satisfy only Category 1. High data requires two of the three data categories — meaning you also need either an independent test interpretation or an external-physician discussion.

5. Using the wrong Medicare prolonged-service threshold 

Medicare G2212 starts at 89 total minutes with 99205 — not at 75 minutes. CPT 99417 begins at 75 minutes but does not apply to Medicare claims. Billing G2212 at 75-88 minutes is a denial.

Frequently asked questions about CPT 99205

Here are some commonly asked questions about CPT 99205: