New patient office or outpatient visit requiring high-complexity medical decision making, or 60–74 minutes of total time on the date of encounter.

Verified May 8, 2026 · 7 sources ↓

Medicare: $236.81
Total RVUs: 7.09
Global, days
Region: General

Drawn from AAOSOhfamaCMSMedsolercmSiriussolutionsglobal

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 7 cited references ↓

Select code basis explicitly: state either total time in minutes or the MDM pathway used (not both required, but one must be clearly documented).
If time-based: document total minutes spent on all qualifying activities on the date of encounter, including non-face-to-face work.
If MDM-based: document complexity of problems addressed, data reviewed and analyzed, and risk of treatment or management options at the high level.
Record a medically appropriate history and physical examination — neither drives level selection, but both must be present and appropriate to the clinical situation.
For same-day procedures: document a separate, independently identifiable chief complaint, assessment, and plan in the E/M note beyond the procedure decision.
For prolonged services (G2212 or 99417): document total minutes exceeding 74, description of activities performed during extended time, and confirmation that separately billed services are excluded from the count.

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

25 Significant separate E/M 52 Reduced services 95 Modifier

What this code covers

Source · Editorial summary grounded in 7 cited references ↓

99205 is the highest-level new patient outpatient E/M code. Select it when the encounter meets either of two thresholds: high-complexity MDM, or total time on the date of service between 60 and 74 minutes. Under the 2021 AMA guidelines — in effect since January 1, 2021 — history and physical exam are no longer drivers of level selection; they must be medically appropriate but don't determine the code. MDM at the high level requires meeting criteria across two of three elements: number and complexity of problems, amount and complexity of data reviewed, and risk of complications or morbidity/mortality.

Time-based selection counts all qualifying time on the date of encounter, including non–face-to-face work such as reviewing records, coordinating care, and documenting — not just the in-room visit. If total time runs 75 minutes or more, add G2212 for prolonged services (Medicare); the first unit of G2212 applies at 89–103 minutes. 99417 is the AMA-designated prolonged service add-on for non-Medicare payers. Never bill G2212 for fewer than 15 additional minutes beyond the 74-minute ceiling of 99205.

Global period is XXX — no surgical global applies. When 99205 is billed same-day as a procedure or injection, modifier 25 is required to show the E/M is significant and separately identifiable. Being a new patient alone does not justify a separate E/M when a minor procedure is performed; the note must stand on its own with its own complaint, assessment, and plan beyond the procedure decision.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	3.5
Practice expense RVU	3.23
Malpractice RVU	0.36
Total RVU	7.09
Medicare national rate	$236.81
Global period	days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$236.81

Common denial reasons

The recurring reasons claims for CPT 99205 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Upcoding pattern flag: billing 99205 for a disproportionately high percentage of new patient visits without clinical complexity distribution to support it.
Modifier 25 missing or unsupported when 99205 is billed same-day as a procedure — note lacks a distinct complaint, history, and plan beyond the procedure.
Time-based selection claimed but total time not documented, or note conflates face-to-face time only rather than total encounter-date time.
New patient status used to justify the level — being new to the practice is not independently sufficient to support 99205; MDM or time must qualify independently.
Prolonged service add-on (G2212) billed when total time did not reach the 89-minute minimum threshold above the 99205 ceiling.

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 7 cited references ↓

01Can I use 99205 based on time alone, or do I need to satisfy MDM?

Either pathway works independently under the 2021 guidelines. Document total time on the date of service between 60 and 74 minutes, or meet high-complexity MDM across two of the three MDM elements. You don't need both, but you must clearly commit to one in the note.

02Does being a new patient automatically support billing 99205?

No. New patient status affects which code range applies (99202–99205 vs. 99211–99215), but it does not by itself justify the highest level. The time or MDM threshold must be independently met.

03When do I add G2212 versus 99417 for prolonged time beyond 74 minutes?

Use G2212 for Medicare patients; use 99417 for commercial payers that follow AMA guidelines. The first add-on unit applies at 89–103 minutes total. Billing G2212 for a visit under 89 minutes will deny.

04If I perform an injection the same day as a new patient visit, do I need modifier 25 on 99205?

Yes. Modifier 25 is required to show the E/M is significant and separately identifiable from the procedure. The note must include its own complaint, history, assessment, and plan that go beyond the decision to perform the injection. Different diagnoses are not required, but the documentation must stand alone.

05What is the prolonged services minimum for G2212 billing with 99205?

G2212 requires at least 15 additional minutes beyond the 74-minute ceiling of 99205, making 89 minutes the hard floor for the first unit. Document total minutes and the activities performed during the extended time.

06Does history and physical exam length still affect level selection for 99205?

No. Since January 1, 2021, history and exam are not used to select the level for office and other outpatient codes (99202–99215). They must be medically appropriate and documented, but they don't drive the code up or down.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures total encounter time across all qualifying activities — chart review, counseling, care coordination, and documentation — and flags the MDM elements addressed, including problem complexity, data sources reviewed, and management risk. This prevents the most common 99205 audit trigger: a note that claims high complexity or 60-plus minutes without specifics to back either pathway.

See how Mira captures CPT 99205 documentation