If you’ve ever felt uncertain about whether your time, clinical effort, and documentation truly warrant a Level 5 new patient visit, you’re not alone. CPT code 99205 often sits on the edge of decision-making for providers handling complex cases. 

It’s the highest-level new patient E/M code, designed for encounters that demand the most time, effort, and clinical judgment. But here's the problem—many providers either underbill and lose revenue or overcode and risk denials or audits. 

The proper use of 99205 isn’t just about knowing the definition—it’s about understanding when this code is truly appropriate, how it stacks up against similar E/M codes, and how to support it with bulletproof documentation.

In this detailed guide, we’ll break down the exact requirements for CPT 99205, including time thresholds, medical decision-making criteria, and Medicare reimbursement rates.

What is CPT code 99205?

CPT code 99205 is an Evaluation and Management (E/M) code for a new patient office or other outpatient visit. It represents the highest-level new patient E/M service (level 5) and requires a high complexity of medical decision-making (MDM).

CPT Code 99205 Is Found In Which Section of The CPT Manual?

In the CPT manual, 99205 is found under the Evaluation and Management section, specifically in the “Office or Other Outpatient Services – New Patient” subsection. In practice, CPT 99205 is used when a new patient requires comprehensive care.

For example, when managing serious or multiple conditions that involve intensive decision-making or extended visit time.

Since the 2021 E/M code revisions, code selection for 99205 is based on either high MDM or time (whichever is met). Historically, 99205 documentation required a comprehensive history and exam with a high MDM, but current AMA guidelines allow using an appropriate history or exam plus a high MDM. 

Typical examples might include an elderly patient with multiple chronic diseases flaring, or a patient with a complex new diagnosis requiring elaborate diagnostic work-up. The CPT 99205 code descriptor reads: “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.

CPT 99205 Time Requirement and Documentation

For CPT 99205, the total time on the day of the encounter must meet or exceed 60 minutes. In other words, if you document that at least 60 minutes (up to 74 minutes) were spent on the date of service (face-to-face and related work), you may select 99205 based on time alone. 

This time threshold aligns with AMA guidelines: code 99205 is listed as requiring 60–74 minutes of total time. For practical reference, coding manuals note a midpoint of approximately 65 minutes as the typical length of a 99205 visit. (For even longer visits, prolonged service codes such as 99417 may be used, but these cannot be reported with 99205 if time exceeds 74 minutes without using the add-on.)

Documentation Guidelines for CPT 99205

Documentation for 99205 must support high-complexity MDM. Include a medically appropriate history and/or exam. Under the current guidelines (2021–2025), only one of history or exam is required, and emphasis is placed on medical decision-making. 

You should document enough history/exam to justify an outpatient visit – typically a comprehensive history and exam or at least detailed elements – but the critical factor is the complexity of the case (see MDM below). In practice, 99205 charts often include extensive review of records, ordering or interpreting many tests, and detailed risk/benefit discussion. Important elements include:

• History/Exam: Either a comprehensive or focused exam is acceptable, but must be medically appropriate for the patient’s problems. (Note: AMA guidelines do not require all 1995/1997 “history and exam bullet points” for 99205 – they only require a level of exam commensurate with high-level visit complexity.)

• Medical Decision Making: All aspects of high-level MDM should be clearly documented (see below). This includes listing the problems/diagnoses addressed, tests ordered and reviewed, and the management options or risks considered.

• Counseling/Coordination: If ≥50% of encounter is counseling or coordination, that should be documented (though time or MDM is still used for code selection).

Providers should ensure the note “tells the story” of a complex visit: a patient with multiple severe conditions, extensive work-up, and significant treatment decisions. Failure to document the extensive decision-making or to meet time can trigger audits (common pitfalls include insufficient chart detail or using 99205 when the encounter was shorter/less complex than required.

Medical Decision-Making (MDM) for 99205

AMA’s current MDM framework defines four levels (straightforward, low, moderate, high). High MDM typically means meeting at least two out of three subcategories at the high level. For 99205, this usually involves:

• Problems: One or more high-severity problems or chronic illnesses with severe exacerbations (or an acute condition threatening life) For example, “a patient with severe congestive heart failure exacerbation” or “a new onset diabetic ketoacidosis” would meet this criterion.

• Data: Extensive data review or ordering – e.g. multiple lab/imaging studies ordered or reviewed (any 3 of these: reviewing prior notes, reviewing test results, ordering tests, etc.). Or independent interpretation of tests (e.g. x-ray read) or discussion with other professionals can count.

The guidelines call this “Category 1: Tests/Reports”, requiring a combination of 3 elements, or “Category 2/3” which involve independent test interpretation or extensive coordination.

• Risk: High risk of morbidity/mortality from the patient’s condition, diagnostics, or treatment. Examples include intensive drug therapy requiring monitoring, or major surgery decisions. AMA specifically lists scenarios like “drug therapy requiring intensive monitoring for toxicity” or “decision regarding emergency major surgery” as high risk.

99205 CPT Code Reimbursement for Medicare 

Reimbursement varies significantly based on geographic MAC localities, with different rates for non-facility (e.g., physician office) and facility (e.g., hospital outpatient department) settings.

The table below highlights selected 2025 Medicare reimbursement rates for CPT 99205 across multiple MAC localities. These values reflect the non-facility price and the facility price as established in the current CMS fee schedule.

HCPCS Code	Mac Locality	Non-Facility Price	Facility Price	Non-Facility Limiting Charge
99205	0	$215.75	$175.64	$235.71
99205	111205	$257.97	$201.05	$281.83
99205	111209	$260.51	$202.96	$284.61
99205	111251	$245.43	$192.88	$268.13
99205	111252	$258.24	$201.32	$282.13
99205	111253	$244.87	$192.32	$267.52
99205	111254	$222.47	$178.63	$243.05
99205	111255	$221.01	$177.17	$241.45
99205	111256	$221.01	$177.17	$241.45
99205	111257	$221.01	$177.17	$241.45
99205	111258	$221.01	$177.17	$241.45
99205	111259	$221.01	$177.17	$241.45
99205	111260	$221.01	$177.17	$241.45
99205	111261	$221.01	$177.17	$241.45
99205	111262	$224.66	$180.82	$245.44
99205	111263	$229.04	$182.67	$250.23
99205	111264	$229.98	$183.25	$251.25
99205	111265	$262.05	$204.50	$286.29
99205	111266	$231.97	$183.48	$253.43
99205	111267	$235.21	$185.79	$256.96
99205	111268	$221.01	$177.17	$241.45
99205	111269	$221.01	$177.17	$241.45
99205	111270	$221.01	$177.17	$241.45
99205	111275	$221.01	$177.17	$241.45
99205	118217	$231.61	$184.16	$253.03
99205	118218	$234.86	$186.96	$256.58
99205	118271	$221.12	$177.28	$241.57
99205	118272	$231.70	$183.93	$253.13
99205	118273	$224.58	$179.18	$245.35
99205	118274	$229.42	$182.29	$250.64
99205	121201	$224.56	$178.48	$245.33
99205	131200	$214.04	$173.93	$233.83
99205	210201	$275.29	$231.93	$300.75
99205	220200	$201.40	$164.98	$220.03
99205	230201	$223.22	$178.98	$243.87
99205	230299	$210.54	$171.00	$230.02
99205	240202	$239.14	$190.21	$261.26
99205	240299	$218.04	$176.32	$238.21
99205	310200	$211.86	$172.75	$231.45
99205	320201	$215.51	$175.40	$235.44
99205	330201	$210.44	$170.33	$229.90
99205	340202	$208.95	$168.84	$228.28
99205	350209	$208.85	$171.43	$228.17
99205	360221	$212.88	$172.77	$232.57
99205	411201	$219.61	$177.37	$239.92
99205	421205	$209.22	$172.80	$228.57
99205	431200	$203.72	$167.98	$222.56
99205	441209	$215.63	$175.28	$235.58
99205	441211	$216.28	$175.89	$236.29
99205	441215	$215.74	$175.63	$235.70
99205	441218	$222.11	$181.88	$242.65
99205	441220	$206.29	$170.07	$225.37
99205	441228	$215.74	$175.71	$235.69
99205	441231	$219.02	$177.06	$239.28
99205	441299	$209.99	$172.09	$229.41
99205	510200	$201.82	$165.20	$220.48
99205	520200	$202.09	$165.75	$220.78
99205	530201	$211.29	$173.11	$230.84
99205	530202	$210.90	$172.88	$230.41
99205	530299	$202.56	$168.10	$221.29
99205	540200	$200.50	$163.72	$219.04
99205	610212	$216.87	$180.05	$236.93
99205	610215	$227.05	$185.02	$248.05
99205	610216	$229.84	$188.81	$251.11
99205	610299	$211.89	$175.31	$231.49
99205	620200	$210.34	$169.23	$229.80
99205	630200	$204.46	$166.07	$223.37
99205	710213	$197.63	$163.14	$215.92
99205	720201	$211.52	$174.01	$231.08
99205	720299	$204.66	$169.32	$223.59
99205	730200	$199.65	$165.48	$218.12
99205	810200	$202.95	$165.97	$221.72
99205	820201	$222.71	$183.16	$243.31
99205	820299	$209.51	$172.97	$228.89
99205	910203	$224.04	$184.01	$244.76
99205	910204	$234.72	$193.53	$256.43
99205	910299	$215.39	$177.69	$235.32
99205	920220	$216.19	$175.80	$236.19
99205	920250	$216.19	$175.80	$236.19
99205	1011200	$199.09	$164.23	$217.50
99205	1021201	$216.88	$176.89	$236.95
99205	1021299	$206.42	$171.00	$225.51
99205	1031235	$201.22	$165.28	$219.83
99205	1120201	$205.77	$169.15	$224.81
99205	1130200	$211.82	$172.35	$231.41
99205	1140216	$206.78	$172.21	$225.91
99205	1150200	$205.29	$168.15	$224.28
99205	1210201	$215.48	$175.69	$235.41
99205	1220201	$241.63	$193.82	$263.98
99205	1230201	$228.55	$185.32	$249.70
99205	1230299	$218.28	$177.53	$238.47
99205	1240201	$239.09	$192.09	$261.21
99205	1240299	$230.97	$186.61	$252.33
99205	1250201	$225.27	$183.03	$246.10
99205	1250299	$208.24	$171.06	$227.51
99205	1310200	$228.85	$185.09	$250.02
99205	1320201	$245.52	$198.75	$268.23
99205	1320202	$251.44	$203.31	$274.70
99205	1320203	$233.62	$189.26	$255.23
99205	1328299	$208.14	$170.07	$227.39
99205	1329204	$246.04	$198.11	$268.80
99205	1411203	$213.07	$172.48	$232.78
99205	1411299	$203.94	$167.32	$222.80
99205	1421201	$237.37	$189.36	$259.33
99205	1421299	$221.02	$178.46	$241.46
99205	1431240	$217.74	$176.27	$237.88
99205	1441201	$220.49	$178.82	$240.89
99205	1451250	$209.81	$169.98	$229.22
99205	1510200	$203.53	$168.36	$222.36
99205	1520200	$207.97	$171.43	$227.20

 

CPT 99245 vs CPT 99205

CPT 99245 and CPT 99205 is essential to ensure appropriate code selection, accurate documentation, and proper reimbursement. While both are high-level new patient codes, they are used in distinct settings and have different documentation and medical decision-making (MDM) requirements.

 1. Code Definition & Setting

Code	Description	Setting
99205	Office or other outpatient visit for a new patient, requiring high-level MDM or 60-74 minutes of total time	Office/Outpatient
99245	Consultation for a new or established patient, requiring high level MDM or 55+ minutes	Office/Outpatient (Consultation only)

• 99205 is part of the standard E/M series (99202–99205) used for new patient office visits.
• 99245 is used when a provider is conducting a consultation at the request of another provider and must include documentation of the request, opinion, and report.

2. Medical Necessity and Documentation Requirements

Component	99205	99245
Request from another provider	❌ Not required	✅ Required
Report to requesting provider	❌ Not required	✅ Required
Time threshold (2025)	60–74 minutes (total time)	55+ minutes (total time)
Medical Decision Making	High complexity	High complexity
Use of Time-Based Billing	Allowed	Allowed

Consultation codes like 99245 must have referral intent documented, and communication back to the referring provider.

Words By Author

In a landscape where every minute counts and every code carries weight, understanding complex CPT entries like 99205 isn’t just a technical skill—it’s a strategic advantage. The ability to confidently choose between high-level E/M codes, backed by accurate documentation and medical necessity, can directly affect not only your reimbursement but also the operational efficiency of your practice.

Many physicians unintentionally undercode out of caution or confusion, sacrificing rightful revenue and skewing data that drives payer policies. If you're looking to eliminate that uncertainty, consider leveraging expert support like HMS USA LLC’s medical coding services to ensure every code you submit is compliant, accurate, and defensible.

The intent of this guide was simple: equip you with clarity, context, and comparisons that make your decisions stronger and more informed.