CPT 99205 is the highest-level office or outpatient visit for a new patient. It requires a high level of medical decision making, or at least 60 minutes of the provider’s total time on the date of the visit. It fits new patients with severe or life-threatening problems, or visits that lead to decisions such as hospital admission.
CPT 99205 description
99205 is a new patient office or other outpatient visit with a medically appropriate history and/or examination and a high level of medical decision making. When time is used to choose the level, 60 minutes must be met or exceeded.
Who counts as a new patient?
Under CPT, a new patient has not received any professional services from the physician or other qualified health care professional, or from another physician or professional of the exact same specialty and subspecialty in the same group practice, within the past three years. Medicare generally treats a nurse practitioner or physician assistant who works with a physician as the same specialty as that physician. The established patient equivalent is 99215.
New patient levels at a glance
| New patient code | Medical decision making | Or total time on the date of the visit |
|---|---|---|
| 99202 | Straightforward | 15 minutes or more |
| 99203 | Low | 30 minutes or more |
| 99204 | Moderate | 45 minutes or more |
| 99205 | High | 60 minutes or more |
High medical decision making: what supports 99205
Two of the three elements must reach high:
| Element | Moderate (99214 / 99204) | High (99215 / 99205) |
|---|---|---|
| Problems addressed | 1 or more chronic illnesses with exacerbation, progression or side effects; or 2 or more stable chronic illnesses; or 1 undiagnosed new problem with uncertain prognosis; or 1 acute illness with systemic symptoms; or 1 acute complicated injury | 1 or more chronic illnesses with severe exacerbation, progression or side effects of treatment; or 1 acute or chronic illness or injury that poses a threat to life or bodily function |
| Data reviewed and analyzed | At least 1 of 3 categories: any 3 data items (notes, test results, tests ordered, independent historian); or independent interpretation of a test; or discussion with an external physician or other appropriate source | At least 2 of the same 3 categories |
| Risk of patient management | Moderate, for example prescription drug management | High, for example drug therapy requiring intensive monitoring for toxicity, a decision about hospitalization or escalation of care, or a decision about emergency major surgery |
Typical 99205 visits
- A new patient referred with a severe flare of a chronic disease, where admission is considered.
- A new patient with symptoms that could threaten life or bodily function, with outside records reviewed, tests ordered and the case discussed with another specialist.
- Starting a drug that needs intensive monitoring for toxicity.
Billing 99205 by time, and prolonged visits
Count the practitioner’s total time on the date of the visit, including:
- Preparing to see the patient, such as reviewing tests
- Getting or reviewing separately obtained history
- Performing a medically appropriate exam
- Counseling and educating the patient, family or caregiver
- Ordering medications, tests or procedures
- Referring and communicating with other professionals (when not separately reported)
- Documenting in the record
- Independently interpreting results (when not separately reported) and coordinating care
For time well beyond 99205, CPT uses add-on +99417 for each additional 15 minutes. Medicare uses G2212 instead: per the CMS Evaluation and Management Services guide (MLN006764) (opens in a new tab), 99205 plus one unit of G2212 needs 89 to 103 minutes of total time.
Common 99205 mistakes
- Long visit, moderate complexity: billing 99205 by MDM when the problems were moderate. Time can support it only if 60 minutes or more is documented.
- Patient status: the patient was seen by the same specialty in the group within three years.
- Thin documentation: the note does not show the severity or the high-risk decision.
Frequently asked questions
Is 99205 the same as a consultation?
No. Medicare does not pay consultation codes, so new patient visits after a referral are usually billed as 99202 to 99205. Some commercial plans still accept consultation codes.
Does a long new patient visit always qualify?
Only if at least 60 minutes of qualifying time on the date of the visit is documented, or high MDM is met.
Related guides
- CPT 99213: low-complexity established visit
- CPT 99214: moderate-complexity established visit
- 99213 vs. 99214: how to choose the level
- CPT 99215: high-complexity established visit
- CPT 99204: moderate-complexity new patient visit
- CPT 99203: low-complexity new patient visit
- CPT 99212: straightforward established visit
- CPT 99202: straightforward new patient visit
- CPT 99211: nurse visit for an established patient
- CPT 99417: prolonged office visit add-on
- Primary care billing services
- Medical coding services
CPT is a registered trademark of the American Medical Association. This guide summarizes the office visit E/M rules in effect since 2021, with the 2024 time wording, and the CMS Evaluation and Management Services guide (MLN006764) (opens in a new tab). Payer policies and your documentation decide what is billable.
Complex new patients, simple payments?
We make sure complex new patient visits are documented and billed at the level they support.