99205 CPT Code: Description, Time, RVU, Reimbursement, and Cost

CPT Code 99205 is a high-level new patient office visit or outpatient E/M service. Use when the documented encounter is to support high level medical decision making. Alternatively, providers may use the “total time” on the date of service to select 99205. If time dictates the code level, the time range for Medicare would be 60 to 74 minutes.

This guide provides you with the 99205 CPT code description, time, MDM, RVU, reimbursement and cost. It also details documentation requirements and some common billing errors. Where applicable, the data in the article are from 2026 Medicare.

Quick Answer

99205 cpt code is for an E/M Visit for a NEW patient, office or outpatient setting. The service requires high level medical decision making and the level is determined by MDM. Medicare will accept time used for 60 to 74 minutes. The national non-facility reference amount (NFRA) for 2026 will be about $236.81 (pre locality).

Field	Information
CPT code	99205
Patient status	New patient
Setting	Office or other outpatient
MDM level	High
Time when selected by time	60–74 minutes
2026 work RVU	3.50
2026 non-facility PE RVU	3.23
2026 facility PE RVU	0.94
2026 malpractice RVU	0.36
2026 non-facility total RVU	7.09
2026 facility total RVU	4.80
2026 national non-facility reference amount	Approximately $236.81
2026 national facility reference amount	Approximately $160.32

The RVU and payment figures above use the 2026 Medicare Physician Fee Schedule data. Actual Medicare payment varies by locality and geographic adjustments.

What Is the 99205 CPT Code?

The 99205 CPT code is a new-patient office or outpatient evaluation and management code. It represents the highest standard level among the five new-patient office E/M codes. The service involves high-level medical decision making when MDM selects the code. It can also be selected using total practitioner time.

The code is intended for encounters requiring substantial clinical decision making. However, patient complexity alone does not automatically support 99205. The documentation must support the selected E/M level. Current E/M rules also changed how history and examination affect code selection. The history and examination must be medically appropriate. They do not determine the E/M level when MDM or time is used for selection.

99205 CPT Code Description

The 99205 CPT code description identifies a new-patient office or outpatient visit. It represents high-level medical decision making or 60 to 74 minutes of total time. The applicable method depends on how the provider selects the E/M level.

The distinction between MDM and time is important for accurate coding. A provider does not need to document 60 minutes when high-level MDM supports 99205. Conversely, documented time can support 99205 when time is used correctly.

Medicare’s claims processing guidance has 99205 ranging from 60 to 74 minutes. As stated above, the total time is the reportable practitioner time for the date of the service.

When Should 99205 cpt code Be Used?

When the encounter fulfills the criteria for the highest office E/M visit with the new patient, then CPT 99205 should be reported. The provider is required to choose one of the levels (MDM or total time). When MDM is used, the encounter must support high-level medical decision making. The documentation should show the problems addressed, data reviewed, and management risk involved.

When time is used, the provider should document the total reportable time. The time must fall within the applicable range for 99205. The code should not be performed because the patient’s situation would seem to be medically complicated. Services that are documented should be coded and E/M service rules applied.

Who Is Considered a New Patient for 99205 cpt code?

A new patient is typically someone who does not have professional services from the same physician or another physician of the same medical specialty in the same group in the prior three years. This definition is important as it can impact code selection. Patients who are established should not be reported with a new patient code.

The first time the patient visits a specific place is also not necessarily the first time he/she is a new patient. The relationship involves the physician, specialty, group and applicable three-year rule. To prevent any coding issues, the coder should confirm the patient’s status prior to coding 99205. This can help to avoid incorrect new-patient coding.

99205 CPT Code Time

The 99205 CPT code time is 60 to 74 minutes when Medicare time-based selection is used. CMS identifies this range for 99205 in its Medicare claims processing guidance. The time represents total time spent by the reporting practitioner on the date of service. It is not limited to face-to-face interaction. However, only time that qualifies under the applicable E/M rules should be counted.

New-Patient Code	MDM	Medicare Time
99202	Straightforward	15–29 minutes
99203	Low	30–44 minutes
99204	Moderate	45–59 minutes
99205	High	60–74 minutes

This table is useful when comparing the five new-patient E/M levels. The codes increase as the supported MDM or time increases.

Does 99205 Require 60 Minutes?

No, 99205 does not always require 60 minutes. The provider can select the code based on high-level MDM instead of time. The 60 to 74 minute range applies when time is used to select 99205. Therefore, a high-MDM encounter can support 99205 without reaching 60 minutes.

This distinction prevents a common coding mistake. Coders should not automatically reject 99205 because the documented time is below 60 minutes. They should first determine whether MDM independently supports the code. The opposite is also important. A long encounter does not automatically justify 99205. The documented time must qualify under the applicable E/M rules.

What MDM Level Is Required for 99205 cpt code?

CPT 99205 requires high-level medical decision making when MDM is used for code selection. MDM is evaluated through three major elements. These elements include problems addressed, data reviewed and analyzed, and risk of patient management.

MDM Element	What the Documentation Should Address
Problems addressed	Number and complexity of conditions addressed
Data	Tests, records, independent interpretation, or discussion
Risk	Risk associated with patient management

The provider must meet the applicable requirements for high-level MDM. A lengthy note alone does not establish high MDM. Similarly, a serious diagnosis does not automatically create high MDM. The documented work and management decisions must support the selected level.

How Does High-Level MDM Support 99205 cpt code?

High MDM generally involves substantial complexity in the problems addressed, data reviewed, or management risk. The provider’s documented work must satisfy the applicable E/M requirements.

For example, a new patient may present with multiple serious conditions. The provider may review extensive information and make complex management decisions. If the documented MDM meets the high-level requirements, 99205 may be appropriate.

Another patient may have a serious diagnosis but require limited decision making. In that situation, the diagnosis alone would not support 99205. The coding decision should therefore focus on what was addressed and managed during the encounter. It should not focus only on the patient’s overall medical history.

99205 CPT Code Documentation Requirements

Documentation should support the medical necessity and level of service reported. It should also support the selected MDM or total time methodology. A strong 99205 record should clearly describe the conditions addressed. It should also explain relevant data reviewed and management decisions made.

When time determines the code, the record should support the total reportable time. Medicare’s E/M guidance uses total time on the date of service for time-based selection.

Useful documentation may include:

• Reason for the encounter
• Conditions addressed
• Assessment and management decisions
• Relevant data reviewed
• Tests or records reviewed
• Independent interpretation when applicable
• Management risks
• Treatment decisions
• Total time when time-based coding is used
• Medical necessity
• Appropriate diagnosis coding

The documentation should tell a clear clinical story. It should explain what the provider evaluated and why the management decisions were necessary.

99205 CPT Code RVU for 2026

The 99205 CPT code RVU has several components under the 2026 Medicare Physician Fee Schedule. CMS assigns separate values for physician work, practice expense, and malpractice expense. For the July 2026 CMS release, CPT 99205 has a 3.50 work RVU. The non-facility practice expense RVU is 3.23. The facility practice expense RVU is 0.94. The malpractice RVU is 0.36.

2026 RVU Component	Non-Facility	Facility
Work RVU	3.50	3.50
Practice Expense RVU	3.23	0.94
Malpractice RVU	0.36	0.36
Total RVU	7.09	4.80

The higher non-facility total reflects the additional practice expense associated with providing the service in an office setting. Facility payment uses the lower facility practice expense component. CMS says the RVUs are used to measure the relative resources consumed to provide the services. The payment is then based on the RVUs, geographic adjustments, and the conversion factor.

What Is the 2026 Work RVU for 99205 cpt code?

The 2026 work RVU for CPT 99205 is 3.50. The physician and/or qualified healthcare professional’s “relative work” is referred to as the work RVU.

The work RVU remains the same between facility and non-facility settings. The practice expense component changes between those settings. This distinction is important when calculating total RVUs. The work RVU should not be confused with the total RVU.

99205 cpt code Reimbursement for 2026

There are a number of payment factors that determine the 99205 CPT code reimbursement. Medicare calculates RVUs, applies geographic practice cost indices and the applicable conversion factor.

CMS did finalize two conversion factors for 2026. Qualifying APM participants receive a conversion factor of $33.57. Participants who are not in qualifying APM have a conversion factor of $33.40.

The national payment file for July 2026 is based on the appropriate 2026 conversion factor and RVU information. CMS also makes geographical adjustments to payment.

How Much Does Medicare Pay for 99205 cpt code in 2026?

The non-facility reference amount is the sum of the national GPCI values ($1.000) multiplied by the 2026 non-QP conversion factor ($33.4009), which gives the approximate sum of $236.81. The calculation is based on a total of 7.09 total non-facility RVUs. Multiplying 7.09 by $33.4009 produces approximately $236.81.

For a facility setting, the 4.80 total RVUs produce approximately $160.32 using the same national assumptions.

2026 CPT 99205 Payment Data	Amount
Non-facility total RVUs	7.09
Facility total RVUs	4.80
2026 non-QP conversion factor	$33.4009
National non-facility reference amount	$236.81
National facility reference amount	$160.32

These are national reference amounts at GPCI values of 1.000. Actual Medicare payment can differ by locality and applicable payment adjustments. CMS’s PFS Look-Up Tool applies geographic practice cost indices to calculate locality-specific payment.

Why Does CPT 99205 Reimbursement Vary by Location?

The amount Medicare pays for 99205 cpt code varies from location to location. The CMS uses geographic practice cost indices for the work, practice expense, and malpractice elements. The formula considers each RVU component separately. The adjusted components are then combined and multiplied by the applicable conversion factor.

For example, a locality with higher practice costs can produce a higher payment amount. Another locality can produce a lower amount because its geographic adjustments differ. Therefore, the national $236.81 figure should not be treated as a universal Medicare payment.

99205 CPT Code Cost

The phrase 99205 CPT code cost can refer to several different amounts. A provider’s charge is not necessarily the same as the Medicare allowed amount. The Medicare allowed amount is the amount recognized under the applicable fee schedule. The patient’s responsibility can then depend on deductible, coinsurance, and supplemental coverage.

There’s commercial insurance as well. Insurers, plans, providers and geographic location each have different contracted rates. As a result, there are no national norms for the actual cost to the patient for CPT 99205.

99205 CPT Code Charge vs Reimbursement

A provider may establish a charge for 99205. That charge can differ substantially from the payer’s allowed amount. Reimbursement refers to the amount paid under the applicable payer arrangement. Medicare reimbursement follows its fee schedule methodology. Commercial reimbursement usually follows contractual payment terms.

These amounts should not be used interchangeably.

For example, a provider could charge $350 for 99205. Medicare may recognize a lower allowed amount based on the applicable locality. The patient’s responsibility would then depend on Medicare rules and supplemental coverage.

Feature	99204	99205
Patient	New	New
MDM	Moderate	High
Medicare time	45–59 minutes	60–74 minutes
Relative level	Lower	Higher

A new patient does not automatically qualify for 99205. The documentation must support high MDM or the applicable time range.

Similarly, a 99204 should not be upgraded simply because the appointment lasted longer. The selected level must match the documented coding methodology.

99205 vs 99215

Both codes (99205 and 99215) are for E/M (Evaluation and Management) high level office and outpatient codes. However, they apply to the various patient-status categories.

Feature	99205	99215
Patient	New	Established
MDM	High	High
Medicare time	60–74 minutes	40–54 minutes
E/M category	New patient	Established patient

This comparison exemplifies the importance of being a patient. 99205 is not required for a high complexity visit. Consider the use of the appropriate code family for an established patient. The documentation and applicable E/M rules are still the final codes.

99205 cpt code and G2211

G2211 is a separate Medicare add-on code associated with certain office and outpatient E/M services. It addresses visit complexity inherent to ongoing care relationships or certain focal-point care situations. Its use should not be assumed for every 99205 encounter. The encounter must satisfy the applicable Medicare requirements.

This distinction matters because G2211 is separate from the E/M level itself. It does not increase 99205 from one level to another. Coders should verify current Medicare policy before reporting G2211 with 99205.

99205 cpt code and G2212

G2212 is a prolonged office or outpatient E/M add-on code. It can apply when the primary E/M service is selected using total time and the encounter exceeds the maximum time required for that code.

For 99205, Medicare provides the following time thresholds:

Services Reported	Total Time
99205	60–74 minutes
99205 + 1 G2212	89–103 minutes
99205 + 2 G2212	104–118 minutes
99205 + 3 G2212 or more	119 minutes or more

CMS specifically provides these thresholds in its Medicare Claims Processing Manual. G2212 should not be reported simply because an appointment lasted longer than 74 minutes. The service must meet the applicable prolonged-service requirements. The provider should also document the total time supporting the reported services.

Can 99205 cpt code Be Selected by Time?

Yes. CPT 99205 can be selected using total time when the documented time meets the applicable requirement. For Medicare, the time range is 60 to 74 minutes. The total includes reportable practitioner time on the date of service.

Time-based selection can include qualifying work performed before and after direct patient interaction. However, the time must be attributable to the encounter and meet the applicable E/M rules. Coders should avoid using scheduled appointment length as a substitute for documented total time.

Common 99205 cpt code Billing Mistakes

Coding 99205 Because the Patient Is Complex

A complex medical history does not automatically establish high MDM. The provider must document the work performed during the encounter.

Using Appointment Length Instead of Reportable Time

A scheduled 60-minute appointment does not automatically support 99205. The record should support the actual reportable practitioner time.

Ignoring Patient Status

99205 is a new-patient code. Established patients generally require the established-patient E/M code family.

Confusing MDM With Documentation Length

A long note does not automatically demonstrate high MDM. Coding should focus on the actual MDM elements documented.

Using Outdated RVU Data

RVUs change over time. A 2024 or 2025 RVU should not be presented as the 2026 value.

CMS maintains annual Physician Fee Schedule relative-value files. The 2026 files include January, April, July, and October releases.

Treating RVUs as Reimbursement

An RVU is not a fixed dollar payment. Medicare applies geographic adjustments and a conversion factor before calculating payment.

Assuming Commercial Payers Follow Medicare

Commercial payer contracts can use different payment policies. A Medicare payment amount should not be presented as the reimbursement rate for every insurer.

Real-World 99205 cpt code Examples

Example 1: High MDM Supports 99205

A new patient presents with multiple significant conditions requiring complex management. The provider evaluates the conditions and makes substantial management decisions. The documented MDM meets the high-level requirements.

In this situation, 99205 may be appropriate based on MDM. The provider does not need to reach 60 minutes when MDM independently supports the code.

Example 2: Time Supports 99205

A new patient receives an extensive evaluation. The provider documents 68 minutes of qualifying total time on the date of service. The encounter does not rely on MDM for level selection.

Under Medicare’s time methodology, 68 minutes falls within the 60 to 74 minute range for 99205.

Example 3: Long Visit Does Not Automatically Support 99205

A new patient remains in the office for more than one hour. However, the provider does not document sufficient reportable time or high-level MDM.

The visit should not automatically be coded as 99205. The documentation must support one of the valid level-selection methods.

Telehealth and Software Billing Considerations for CPT 99205

CPT 99205 may be reported for an eligible telehealth encounter when applicable requirements are met. The service must still support the required E/M level. Telehealth does not automatically justify a higher level of service. The provider must document the medical necessity, MDM, or qualifying total time. Payer-specific telehealth policies should also be reviewed before submitting the claim.

What POS Codes Apply to 99205 Telehealth?

For Medicare professional claims, telehealth services provided to a patient outside their home generally use POS 02. Services provided while the patient is at home generally use POS 10. CMS states that POS 10 represents telehealth provided in the patient’s home.

This distinction can affect Medicare payment. CMS states that POS 10 services are paid using the non-facility rate. POS 02 represents telehealth provided somewhere other than the patient’s home.

Does Modifier 95 Apply to 99205 Telehealth?

Modifier 95 can be used with CPT 99205 if it is furnished through qualifying synchronous audio video telehealth. But requirements for modifiers do vary from payer to payer. There are two modifier options available for Medicare claims, one for audio only services (modifier 93) and one for audio-video telehealth (modifier 95).

Coders should not add modifier 95 simply because the appointment occurred through software. The technology must support the type of telehealth service being reported. The applicable payer’s current billing instructions should always be checked.

Can 99205 Be Billed Through Telehealth Software?

Yes, eligible 99205 services can be furnished through telehealth technology when coverage requirements are satisfied. The software itself does not determine whether the service is billable. The encounter must meet the applicable Medicare or commercial payer requirements.

The platform should support the required communication method. It should also provide adequate documentation for the encounter. Providers should maintain records supporting the service, including the encounter date, participants, clinical work, and applicable time or MDM information.

Software Documentation for 99205

Telehealth software can help capture encounter information. However, software-generated documentation does not replace the provider’s clinical documentation. The medical record should support the actual service performed.

For time-based 99205 coding, documentation should support the qualifying total time. For MDM-based coding, documentation should support the applicable problems, data, and management risk. Software timestamps can support documentation. They should not be treated as automatic proof of billable time. The provider remains responsible for ensuring that reported time accurately reflects qualifying E/M work.

Telehealth Billing Mistakes With CPT 99205

Several mistakes can create claim problems. One common mistake is using the wrong POS code. Another is applying a modifier without checking the payer’s requirements. Providers may also assume that a virtual encounter automatically qualifies for 99205. It does not. The same E/M level-selection principles must support the reported service.

Another problem involves software time. A platform may show that a provider was connected for 60 minutes. That does not automatically establish 60 minutes of reportable E/M time. The medical record should support the actual service. Payers may also apply additional telehealth coverage or documentation requirements. CMS specifically advises checking individual payer policies for POS and reimbursement questions.

2026 Telehealth Billing Reminder

For 2026 Medicare billing, verify the current telehealth rules before submitting CPT 99205. CMS continues to update telehealth policies through the Physician Fee Schedule and related guidance.

For commercial insurance, do not assume Medicare’s rules apply. Aetna, BCBS, Cigna, and other insurers may have different telehealth requirements. The payer’s current policy should control when it differs from general Medicare guidance.

CPT 99205 Audit Considerations

A 99205 audit should compare the claim with the complete medical record. The auditor should determine whether the patient was new and whether the selected methodology was supported. If MDM was used, the auditor should review the documented problems, data, and risk. If time was used, the auditor should review the documented total time.

The audit should also review medical necessity. A technically complete note does not automatically establish that the service was reasonable and necessary. Payment information should also be reviewed carefully. The applicable Medicare locality, facility status, conversion factor, and other payment adjustments can affect reimbursement.

99205 Coding Checklist

Before submitting a 99205 claim, review the following:

• Confirm the patient qualifies as new.
• Confirm the service occurred in an appropriate office or outpatient setting.
• Determine whether MDM or time selected the code.
• Confirm high-level MDM when MDM is used.
• Verify total time when time is used.
• Confirm medical necessity.
• Ensure the documentation supports the selected level.
• Review diagnosis coding.
• Check applicable payer requirements.
• Verify modifier requirements when applicable.
• Review NCCI and other applicable claim edits.
• Use current 2026 payment information when discussing reimbursement.

This checklist helps separate coding decisions from payment assumptions. It also helps prevent outdated information from being carried into current claims.

99205 CPT Code: Key Takeaways

The 99205 CPT code represents a high-level new-patient office or outpatient E/M service. It can be selected through high-level MDM or total time. For Medicare, 60 to 74 minutes supports 99205 when time determines the level. Longer encounters may qualify for G2212 when all applicable prolonged-service requirements are satisfied.

Using the 2026 non-QP conversion factor and national GPCI values, the reference amounts are approximately $236.81 for non-facility and $160.32 for facility services. Actual Medicare payment varies by locality and applicable adjustments.

The most important coding principle is simple. 99205 should reflect the documented service, not the expected reimbursement.

Frequently Asked Questions About CPT 99205