CPT Code 99205: Office or Other Outpatient Visit for New Patients

What is CPT code 99205?

CPT code 99205 represents the highest level of evaluation and management services for new patients during office or outpatient visits. It applies to cases requiring high medical decision making, such as complex diagnoses or urgent conditions threatening life or function. Providers can select this code based on either 60-74 minutes of total time spent on the visit date (including chart review, care coordination, and documentation) or a medically appropriate history/examination paired with high-complexity decision-making.

The 99205 CPT code is distinguished by its use for new patients only—defined as individuals who have not received professional services from the physician or qualified healthcare professional, or another physician or qualified healthcare professional of the same specialty and subspecialty in the same group practice, within the past three years.

The 99205 CPT code is typically appropriate for scenarios such as:

• Initial evaluation of a patient with multiple complex medical problems requiring extensive workup and medical services.
• New patient with severe symptoms indicating a potentially serious condition with clear medical necessity for a comprehensive assessment.
• Evaluation of a patient with a new diagnosis of a life-threatening illness requiring extensive discussion of treatment options.
• Initial assessment of a complex psychiatric condition with significant risk factors.

CPT code 99205 documentation requirements

To support accurate medical billing, compliance, and proper reimbursement, documentation must include:

• Detailed medical history: A detailed account of the patient’s medical history and patient's medical background including past illnesses, surgeries, family history, and social factors.
• Comprehensive examination: A thorough medically appropriate physical assessment covering multiple body systems.
• High medical decision making: Evidence of analyzing complex data (e.g., imaging, lab results), managing significant risks (e.g., acute organ failure), or addressing multiple diagnoses requiring urgent intervention compared with straightforward medical decision making.
• Time tracking: Clear and proper documentation of the 60-74-minute history or examination comprehensive session length, specifying activities like reviewing records or counseling the patient.

Healthcare providers must properly document with key components, evaluate with other established patient codes to abide with coding guidelines, and include essential medical records to ensure accurate billing, maximize reimbursement rates, and minimize delay.

CPT code 99205 billing guidelines

Understanding the accurate billing guidelines for CPT code 99205 is essential for seamless reimbursement processes and compliance with payer requirements.

• Medical necessity: Use billing CPT code 99205 for patients with acute, unstable, or high-risk conditions (e.g., severe chest pain with suspected myocardial infarction).
• Code selection: Choose based on time or medical decision making—whichever justifies the higher level of care.
• Common mistakes: Avoid upcoding for stable chronic conditions or omitting documentation of time spent and evaluate the appropriate code to be used.

Other relevant CPT codes

When providing evaluation and management services to new patients in the office or other outpatient setting, several related CPT codes may be relevant:

• 99203: New patient visits with low complexity medical decision making
• 99204: New patient visits with moderate complexity medical decision making
• 99215: Established patient visit requiring high complexity decision-making (40-54 minutes)
• 99211: Minimal-complexity visit for established patients, often used for nurse-led services (5 minutes)