CPT 99205: New Patient Office Visit, High Complexity
CPT 99205 reports a new patient office or outpatient visit with high medical decision making or 60-74 minutes of total time. It is the top new-patient level. In 2026 Medicare pays about $236.81 non-facility (7.09 total RVUs times the $33.4009 conversion factor) and about $160.32 in a facility.
- Code type
- New patient E/M (office/outpatient)
- 2026 non-facility
- $236.81 (7.09 RVUs)
- 2026 facility
- $160.32 (4.80 RVUs)
- Time (if used)
- 60-74 minutes total on the date
What is CPT 99205 used for?
CPT 99205 is an office or outpatient visit for a new patient requiring high medical decision making or 60-74 minutes of total time. It is the highest new-patient level and should reflect genuinely complex initial evaluations, severe or unstable problems, extensive data, or high-risk management decisions.
You select the level by MDM or by total time under the 2021 E/M framework; history and exam must be medically appropriate but no longer set the code. New-patient status still turns on the three-year rule, no prior face-to-face service from you or a same-specialty and subspecialty physician in your group. Because 99205 is the top-paying new-patient visit, it draws payer scrutiny, so the record has to show the severity and the high-risk management, not simply a long history.
How much does 99205 pay in 2026?
99205 carries 7.09 non-facility RVUs and 4.80 facility RVUs. At the 2026 conversion factor of $33.4009:
| Setting | Total RVUs | 2026 Medicare allowed |
|---|---|---|
| Non-facility (office) | 7.09 | ~$236.81 |
| Facility | 4.80 | ~$160.32 |
Medicare pays 80 percent of the allowed amount after the deductible; the balance is patient or secondary coinsurance. Use the Medicare fee calculator for locality-adjusted rates.
What documentation supports a 99205?
High MDM usually means one or more chronic illnesses with severe exacerbation, an acute illness posing a threat to life or bodily function, or a decision about hospitalization, plus extensive data review or high risk such as drug therapy requiring intensive monitoring. Example: a new patient presents with new-onset atrial fibrillation and chest pain; you review outside ECGs and labs, start anticoagulation, and decide whether to admit. That is high problem severity plus extensive data plus high-risk drug management, a defensible 99205 at about $236.81.
Anchor 99205 in the documented high-complexity MDM elements, problem severity, data, and risk, rather than in the length of the history. A distribution that skews to 99205 without matching acuity is a classic upcoding flag, so make the severity and the high-risk decision explicit in the note.
What happens when a 99205 visit runs long?
Once total time exceeds the top of the 99205 range, you add prolonged services in 15-minute increments. The payer split matters:
| Add-on | Payer | Trigger (per CPT / CMS) |
|---|---|---|
| 99417 | Most commercial | 15 min beyond the minimum (75+ min total) |
| G2212 | Medicare | 15 min beyond the maximum time for 99205 |
Frequently asked questions
By time, 99205 requires 60-74 minutes of total time on the date of service. Beyond 74 minutes (or, for Medicare, beyond the maximum), you add a prolonged-services code. If you code by MDM instead of time, high complexity controls and time is not required.
The 2026 national non-facility allowed amount is about $236.81 (7.09 total RVUs times $33.4009). In a facility it is about $160.32 (4.80 RVUs). Medicare pays 80 percent after the deductible; the balance is patient or secondary coinsurance.
High MDM usually means one or more chronic illnesses with severe exacerbation, an acute illness posing a threat to life or bodily function, or decisions about hospitalization, plus extensive data review or high risk such as drug therapy requiring intensive monitoring. Document the severity and the high-risk management to defend the top level.
Sources & further reading
Reviewed by the ImmediCare Solutions RCM team
Certified billers and coders handling claims across 50+ specialties nationwide. This entry is reviewed against current payer policy and CMS rules. Last review: Jul 5, 2026.
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