What Is the 99205 CPT Code?
CPT code 99205 is the highest-level evaluation and management code for a new patient office visit, reporting an encounter that requires either high-complexity medical decision making or 60 or more minutes of total physician time on the date of service. Under the 2026 Medicare Physician Fee Schedule, CPT 99205 reimburses approximately $237 in a non-facility setting and about $160 in a facility setting before geographic adjustment, with commercial payers typically paying more.
Highest new patient E/M code. 99205 requires either high-complexity MDM or 60 or more minutes of total time, and it pays roughly $60 more per visit than 99204.
Prolonged services split by payer. Commercial payers accept CPT 99417 once total time reaches 75 minutes, but Medicare’s HCPCS G2212 does not start until 89 minutes, so billing the wrong code produces denials.
Commonly undercoded. Many family practices default to 99204 out of audit caution, leaving approximately $12,000 a year on the table across four downcoded visits per week.
How Much Does 99205 Pay in 2026?
Under the 2026 Medicare Physician Fee Schedule, CPT 99205 carries a work RVU of 3.17 and a total RVU near 7.09, which pays approximately $237 in the non-facility (office) setting nationally at the 2026 conversion factor of $33.40 before geographic adjustment. The facility payment runs about $160. Commercial payers typically reimburse higher, with published averages in the $250 to $350 range depending on the plan and contract.
| Component | 2026 value | Notes |
|---|---|---|
| Non-facility payment | ~$237 | National Medicare average, office setting |
| Facility payment | ~$160 | Hospital outpatient setting |
| Work RVU | 3.17 | Constant across settings |
| Non-facility total RVU | 7.09 | Drives the office payment |
| Conversion factor | $33.40 / $33.57 | Non-APM / APM, up from $32.35 in 2025 |
| Commercial range | $250 to $350 | Varies by payer and contract |
New patient visits are where a family practice captures or loses the most revenue per encounter, and 99205 sits at the top of that range. It pays the most, it takes the most work to document, and it draws the most audit attention, so practices routinely undercode it to 99204 to stay safe. That caution is expensive.
What Counts as a New Patient for 99205?
A new patient is one who has not received a face-to-face professional service from you, or from another physician of the same specialty in your group practice, within the past three years. If any qualifying visit occurred in that window, the patient is established, and you must use an established-patient code such as CPT 99213 or the 99215 equivalent instead.
The three-year lookback is measured from the date of the last face-to-face service, and specialty is defined by the physician’s Medicare enrollment specialty, not the practice name. Misclassifying an established patient as new is one of the fastest ways to trigger a payer audit, because new-patient codes pay materially more and the claims data makes the pattern obvious.
How to Document 99205 So It Holds Up
A 99205 claim does not fail because the visit was simple. It fails because the note did not prove the level. Build these elements into every high-level new patient encounter:
1. Choose one basis for the code. Either high-complexity MDM or 60 minutes of total time, not a mix of the two.
2. State the total minutes explicitly when billing by time. Use a specific number rather than a range or ‘about an hour.’
3. Break down how the time was spent. Record review, face-to-face visit, counseling, documentation, and care coordination.
4. Name the problems and their severity. Document conditions posing a threat to life or bodily function.
5. Describe the data you reviewed. Outside records, tests ordered, and any independent interpretation.
6. Document the risk. Decisions about hospitalization, drug therapy requiring intensive monitoring, or major surgery.
7. Confirm the three-year new-patient rule before submitting. Verify the visit is not an established encounter in disguise.
What Is the Difference Between 99204 and 99205?
The difference between 99204 and 99205 is complexity and time. CPT 99204 requires moderate-complexity medical decision making or 45 to 59 minutes of total time, while 99205 requires high-complexity decision making or 60 minutes or more. The work RVU jumps from 2.60 for 99204 to 3.17 for 99205, and 99205 pays about $60 more per visit in 2026.
Across the billing companies we vet for family medicine practices, the safe-looking habit of defaulting to 99204 is where a lot of legitimate 99205 revenue disappears. Consider a family practice onboarding new patients across Medicare and commercial plans. Four legitimate 99205 visits a week billed as 99204 out of audit caution costs roughly $240 a week, close to $12,000 a year, before any prolonged-service units lost to the wrong payer code.
How Do Prolonged Services Work After 99205?
When a 99205 visit runs past 74 minutes, prolonged-service add-on codes apply, and the payer determines which one. Commercial payers accept CPT 99417 starting at 75 minutes. Medicare requires HCPCS G2212, which does not begin until 89 minutes. The two codes are not interchangeable, and billing the wrong one produces a denial (source: CMS Medicare Claims Processing Manual, Chapter 12).
| Scenario | Commercial (99417) | Medicare (G2212) |
|---|---|---|
| First unit starts at | 75 minutes | 89 minutes |
| 80-minute visit | 99205 + 99417 x1 | 99205 only |
| 90-minute visit | 99205 + 99417 x2 | 99205 + G2212 x1 |
That 14-minute gap between the two thresholds is one of the most common prolonged-service errors in outpatient billing. An 80-minute new-patient visit earns an extra unit from a commercial plan and nothing extra from Medicare, and a billing team that does not run payer-specific rules will bill both the same way and eat the denials.
New patient visits are the most expensive appointments to earn and the easiest to undercode. A vetted family-medicine billing partner reviews your 99205 documentation, codes to the level the note supports, and applies payer-specific prolonged-service rules so you stop eating denials. Compare free quotes from billing companies matched to your practice.
Can 99205 Be Billed via Telehealth in 2026?
Yes. CPT 99205 is on the 2026 Medicare telehealth services list, and telehealth flexibilities let beneficiaries be seen from any location through December 31, 2027. Bill it with modifier 95 and place of service 02 or 10. The visit must still meet the same high-MDM or 60-minute time requirement as an in-person new patient visit.
Frequently Asked Questions
Can you bill G2211 with 99205?
Yes. The longitudinal complexity add-on code G2211 attaches to new patient codes 99202 through 99205 when you intend to serve as the patient’s continuing focal point for care, as long as the E/M does not carry modifier 25 for a same-day non-preventive procedure.
Is 99205 the same as 99215?
No. CPT 99205 is for new patients and requires a 60-minute time threshold with a higher payment of about $237 in 2026. CPT 99215 is the established-patient equivalent, with a 40-minute threshold and a 2026 rate near $192.
Can nurse practitioners bill 99205?
Yes, when they personally perform the encounter and document high-complexity MDM or 60 or more minutes of total time. Medicare pays nurse practitioners at 85% of the physician fee schedule, roughly $201 for a non-facility 99205, and the code cannot be billed incident-to for a new patient.
Do you have to document time for 99205?
Only when time is the basis for code selection. If you select 99205 on high-complexity MDM, there is no requirement to record total time. If you bill by time, state the exact minutes and describe how they were spent, since a vague note creates audit risk.
What happens if a 99205 visit runs past 74 minutes?
Prolonged-service add-on codes apply, and the payer decides which one. Commercial payers accept CPT 99417 starting at 75 minutes. Medicare requires HCPCS G2212, which does not begin until 89 minutes. The two codes are not interchangeable, and billing the wrong one produces a denial.
Does Medicaid pay for 99205?
Coverage and rates vary by state. Most state Medicaid programs cover new patient office E/M services, generally paying between $130 and $200 for 99205, which is often below the Medicare rate. Verify your state’s fee schedule before billing.
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