99205 CPT Code: Know Your Codes
99205 CPT Code Description
99205 CPT Code: Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and a high level of medical decision making.
When using time for code selection, 60-74 minutes of the total time is spent on the date of the encounter. For services 75 minutes or longer, see ‘Prolonged Services’ i.e. CPT Codes 99354-99357.
A new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. In the instance where a physician/qualified health care professional is on call for or covering for another physician/ qualified health care professional, the patient’s encounter will be classified as it would have been by the physician/qualified health care professional who is not available.
Office/Outpatient E/M Coding (99202-99215) Changes in 2021
Effective with date of service Jan. 1, 2021, the American Medical Association (AMA), which holds copyright in CPT®, and the Centers for Medicare & Medicaid Services (CMS) implemented major revisions related to office and outpatient E/M codes 99201-99215 in 2021. For complete information regarding all CPT codes and descriptions, refer to the 2021 edition of Current Procedural Terminology, published by the AMA. The stated goals were reducing administrative burden, improving payment accuracy, and updating the code set to reflect current medical practice.
|CPT Code||History and/or Exam||MDM||Total Minutes|
History and/or Exam
The History and/or Examination portion of office/outpatient E/M guidelines explains that office and other outpatient E/M services include ‘a medically appropriate history and/or physical examination, when performed.’ ‘Medically appropriate’ means that the physician or other qualified healthcare professional reporting the E/M determines the nature and extent of any history or exam for a particular service. Please note that the code selection does not depend on the level of history or exam.
Medical Decision Making (MDM) for CPT Code 99205
- Level of MDM (Based on 2 out of 3 Elements of MDM): High
Elements of Medical Decision Making
|Number and Complexity of Problems|
|Amount and/or Complexity of Data to be Reviewed and Analyzed||Risk of Complications and/or Morbidity or|
Mortality of Patient Management
1 or more chronic illnesses with
progression, or side effects of
1 acute or chronic illness or
injury that poses a threat to
life or bodily function
(Must meet the requirements of at least 2 out of 3 categories)
Category 1: Tests, documents, or independent historian(s)
Any combination of 3 from the following:
1. Review of prior external note(s) from each unique source*;
2. Review of the result(s) of each unique test*;
3. Ordering of each unique test*;
4. Assessment requiring an independent historian(s)
Category 2: Independent interpretation of tests
Independent interpretation of a test performed by another
physician/other qualified health care professional (not
Category 3: Discussion of management or test interpretation
Discussion of management or test interpretation with external
physician/other qualified health care professional/appropriate
source (not separately reported)
|High risk of morbidity from additional|
diagnostic testing or treatment
1. Drug therapy requiring intensive
monitoring for toxicity
2. Decision regarding elective major
surgery with identified patient or
procedure risk factors
3. Decision regarding emergency major
4. Decision regarding hospitalization
5. Decision not to resuscitate or to deescalate care because of poor
2 or combination of 3 in Category 1
RVUs for CPT 99205
The following table shows the first-quarter 2021 and fourth-quarter 2020 total RVUs for CPT 99205. MPFS facility RVUs are often lower than non-facility (office) RVUs because when a physician provides services in a facility, the physician is responsible for fewer practice expenses. The final reimbursement amounts for E/M services will depend on more than just these RVUs.
|2020 Q4 RVUs||5.85||4.78|
|2021 Q1 RVUs||6.51||5.38|
One policy change in the 2019 MPFS final rule that got a large reaction from providers was a plan to pay a single rate, called a blended rate. In other words, Medicare intended to pay the same rate for new patient codes 99202, 99203, and 99204, regardless of which code was reported. Medicare was going to pay another single rate for established patient codes 99212, 99213, and 99214. Level-5 visits (99205, 99215) would have separate rates to reflect the increased complexity those codes represent.
CPT © Copyright 2021 American Medical Association
We hope that this article has provided basic guidelines about the 99205 CPT code. If you are looking for overall billing and coding services you can refer to E2E Medical Billing Services. Our accurate and affordable billing services will eliminate billing and coding errors and will increase your practice collection. To know more about our medical billing and coding services, call us at 888-552-1290 or write to us at [email protected]