CPT 99205 Description, Billing Rules, & Use Cases
CPT 99205 is used to bill for an office or other outpatient visit with a new patient that requires a high level of medical decision making and/or at least 60 minutes of total provider time spent on the date of the encounter.
This code applies when a physician, nurse practitioner (NP), or physician assistant (PA) evaluates and manages a patient with conditions that demand the highest level of clinical complexity and risk in the outpatient setting. If the encounter extends beyond 74 minutes, the prolonged services add-on code +99417 may also be reported.
The visit may include:
- Obtaining a comprehensive patient history and performing a detailed examination
- Reviewing, ordering, and interpreting multiple diagnostic tests
- Coordinating care with other specialists and healthcare professionals
- Developing or adjusting complex treatment plans
- Counseling the patient and/or caregiver on risks, prognosis, and management strategies
What is CPT Code 99205?
CPT 99205 is an evaluation and management (E/M) code used for new patient office or outpatient visits that require a high level of medical decision making (MDM) or at least 60 minutes of total provider time on the date of the encounter
This code represents the most complex new patient E/M service in the office and outpatient family (99202–99205). It applies when:
- The patient presents with multiple or severe conditions that require extensive evaluation
- The provider spends 60 minutes or more across face-to-face and non–face-to-face activities such as reviewing records, counseling, documentation, ordering/interpreting tests, and coordinating care
- Clinical decisions carry a high risk of complications, morbidity, or mortality
Examples of when CPT 99205 may apply include:
- Initial work-up of a patient with suspected cancer requiring comprehensive testing and specialist coordination
- Evaluation of a new patient with advanced heart failure or other serious chronic conditions requiring complex management
- Psychiatric evaluation for severe mental health conditions needing extensive counseling and care planning
- If the encounter extends 75 minutes or longer, prolonged services code +99417 should be added.
In summary: CPT 99205 is reserved for extended, high-intensity visits with new patients that require the most time and decision-making effort within the outpatient E/M series.
CPT 99205 Time Thresholds and Code Combinations
CPT 99205 is used to report a new patient office or other outpatient visit when the provider spends at least 60 minutes of total time on the date of the encounter, or when the level of medical decision making is high complexity.
Important to Note:
- The 2024 revision specifies that “60 minutes must be met or exceeded” (replacing the older 60–74 minute range).
- If the encounter extends 75 minutes or longer, report prolonged services code +99417 in addition to 99205.
- Total time includes both face-to-face and non–face-to-face provider activities (reviewing tests, documentation, counseling, ordering and interpreting results, and care coordination).
- Do not report 99205 for visits under 60 minutes or when documentation supports only moderate or low complexity.
When to Use CPT 99205: Common Scenarios and Use Cases
CPT 99205 is appropriate when a physician, nurse practitioner (NP), or physician assistant (PA) sees a new patient in the office or outpatient setting, spends at least 60 minutes on the encounter, and the visit involves high-complexity medical decision making.
Here are examples of how CPT 99205 is used in practice:
Complex Cardiology Evaluation for Heart Failure
A cardiologist allocates time to:
- Obtain a comprehensive medical history and review prior hospitalizations
- Perform a detailed cardiovascular exam and order advanced imaging
- Adjust multiple medications, counsel on prognosis, and coordinate with a heart failure specialist team
Total time: 65 minutes
Billing: 99205
Initial Oncology Consultation for Suspected Cancer
An oncology nurse practitioner allocates time to:
- Review extensive lab and imaging results
- Conduct a comprehensive exam and take a detailed family history
- Explain diagnostic pathways, treatment options, and risks, while arranging referrals to subspecialists
Total time: 72 minutes
Billing: 99205
Psychiatric Evaluation for Severe Major Depression with Suicidal Risk
A psychiatric physician assistant allocates time to:
- Gather a comprehensive psychiatric, medical, and social history
- Perform a structured mental health assessment with validated tools
- Develop a crisis management plan, initiate therapy, and coordinate emergency follow-up services
Total time: 75 minutes
Billing: 99205 + 99417 (prolonged services)
CPT 99205 Billing Requirements and Eligibility
CPT 99205 is used to report new patient office or other outpatient visits that involve high-complexity medical decision making or at least 60 minutes of total provider time on the date of the encounter.
These services require thorough documentation to justify the level of time or decision making.
Patient Eligibility Criteria
The patient must:
- Be a new patient (not seen by the same provider group in the last three years)
- Present with severe or multiple problems that require extensive evaluation and high-level clinical judgment
- Be evaluated in an office or other outpatient setting (not hospital, observation, or emergency department)
Provider Requirements
The billing provider must be a:
- Physician (MD or DO)
- Nurse Practitioner (NP)
- Physician Assistant (PA)
The provider must:
- Personally perform the encounter
- Document the time spent or the complexity of MDM
- Ensure all services are recorded in the medical record
Service Requirements
The encounter must include either:
- 60 minutes or more of total provider time (face-to-face and non–face-to-face tasks such as reviewing prior records, performing a comprehensive exam, documenting, counseling, ordering and interpreting tests, and coordinating care)
OR - High-complexity MDM (extensive number of problems, large amount of data to review, and high risk of morbidity or mortality)
Additional requirements:
- For services lasting 75 minutes or longer, append prolonged services code +99417 to 99205
- Time and services must be distinct from other billed encounters on the same date
CPT 99205 vs Related Codes
- 99204 vs 99205: Use 99204 for visits requiring 45–59 minutes or moderate-complexity MDM. Use 99205 for visits requiring 60+ minutes or high-complexity MDM.
- 99205 + 99417: Add prolonged services code +99417 when the encounter extends 75 minutes or longer.
CPT 99205 Billing Documentation Checklist
To support compliant billing for CPT 99205, your medical record should include the following:
- Clear documentation of at least 60 minutes of provider time or evidence that high-complexity medical decision making (MDM) criteria were met
- Time logs (if coding by time) specifying:
- Date of encounter
- Activities performed (e.g., chart review, comprehensive history, physical exam, counseling, documenting, ordering and interpreting tests, coordinating care)
- Total time spent by the physician, NP, or PA
- New patient status confirmed, with no professional service in the last three years from the same provider group
- MDM documentation that demonstrates:
- Multiple or severe conditions addressed
- Extensive data reviewed and/or analyzed
- High risk of complications, morbidity, or mortality
- Details of services performed, including:
- Comprehensive medical and/or psychosocial history
- Medically appropriate physical examination
- Counseling and education provided to patient or caregiver
- Complex treatment planning and coordination with other providers
- Provider attestation verifying that services were personally performed and documentation is accurate
- Statement that reported time did not overlap with other billed services, including preventive visits or additional E/M encounters
- Prolonged services documentation (if billing +99417), including justification for time exceeding 74 minutes
Common CPT 99205 Billing Mistakes (and How to Avoid Them)
❌ Billing Without 60 Minutes of Documented Time
CPT 99205 requires at least 60 minutes if coded by time. Visits under this threshold should be billed as 99204 unless high-complexity MDM is clearly supported.
❌ Using 99205 for Established Patients
This code is only for new patient visits. Established patients must be reported with 99211–99215.
❌ Under-Documenting High-Complexity MDM
If billed by MDM, records must show severe or multiple problems, extensive data review, and high risk. Insufficient documentation often results in downcoding to 99204.
❌ Not Adding Prolonged Services (+99417) When Applicable
Encounters lasting 75 minutes or more require add-on code +99417. Omitting it can result in lost reimbursement.
❌ Counting Non-Provider Time
Only time personally spent by the physician, NP, or PA counts toward the threshold. Support staff or administrative activities cannot be included.
❌ Improper Setting Usage
99205 applies only to office or outpatient visits. Using it for hospital, observation, or ED services is incorrect.
