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99205 CPT Code – Description, Reimbursement, Modifier & Examples

The 99205 CPT code can be reported for office or other outpatient visits of a new patient. The estimated time is between 60 and 74 minutes. This procedure can be billed with modifier 25 and the RVU is 3.50 since 2021.

99205 CPT Code Description

CPT 99205 can be billed for office or other outpatient visits of a new patient. Report this code for office or other outpatient visit for the evaluation and management of a new patient which requires:

  • medically appropriate history; or/and
  • examination and a high level of medical decision making.

How Many Minutes Is The 99205 CPT Code?

Procedure 99205 is estimated between 60 and 74 minutes. The total time needs to be spent on the date of encounter.

If the procedure exceeds 74 minutes; bill prolonged services (CPT 99354CPT 99357).

Guidelines For Time

Revision of time means the total time spent with the patient on the date of the encounter, that recognises face to face and important non face to face activities. Clear time ranges for each code should be documented with easy to remember increments.

When the visit dominates counselling and/or coordination of care, time should ONLY be used for selecting the E&M level.  However, time may be used whether or not counselling and/or coordination of care dominates the service.

Time could be counted for any relevant activities that are not separately reported, starting from preparation to see patient, obtaining history & documenting in medical records, reviewing tests or history, managing the patient by ordering of test, medicines or procedures performing medically necessary examination and/or evaluation, counselling and educating the patient or caretakers or family, interpreting tests or any care coordination.

Note: Do not count time spent on travel, separately reported services or general discussion for management of a patient

How Many RVU Do I Need For 99205?

The RVU for the 99205 CPT code have increased to 3.50 in 2021 form 3.17 in 2020.

99205 CPT Code Reimbursement

CPT 99205 will only be reimbursed if the patient is a new patient. This procedure code means high or level 5 office visit and details of the documentation matters to qualify as “reasonable and necessary”. High complexity or high severity means the risk of death is high without treatment or a probability of severe, prolonged functional or organ impairment. 

Element 1 

The 99205 CPT code can only be coded if the number and complexity of problems is high. To determine if the number of complexity is high the following needs to be confirmed. The number of acute or/and chronic conditions or injury needs to be the same or more with severe exacerbation or side effects of treatment. The clinical notes have to reflect that illness or injury poses a threat to patient’s life or bodily function in the near term without treatment.

Element 2 

The amount or/and complexity of data (ACOD) to be reviewed and analysed needs to be extensive in order to bill CPT 99205. Analysed means the test itself may not be subject to analysis. However, the test is deemed in the thought process of the physician for diagnosis, evaluation or treatment. 

To determine ACOD to be extensive at least 2 out of 3 categories must be met to meet the requirements.

Category 1 

Order Tests – Ordering of each unique test. Data reviewed by physician: 

  • prior external note/notes;
  • result/results of each unique test.

Assessment requiring an independent historian/historians. For example: patient unable to talk or unconscious/disoriented

Category 2 

Independent interpretation of tests performed by another physician/QHP (not separately reported).

For example: Radiology bill with modifier 26 if billed separately can not be considered for counting as it is already billed.

Category 3

Discussion of management or test interpretation.

For example: Discussion with pathologist or a specialist or QHP that are not billed separate.

Note 1: An external physician or other qualified health care professional means who is practicing independently or who is not in the same group practice or from different speciality.

Note 2 : Discussion need not be on same day and may not be face to face, but is counted only once in MDM.

CPT 99205 With Modifier 25

When a minor surgery is performed on the same day as an E&M, separate documentation is required to provide evidence that a separately identifiable service was performed other than the procedure. The billing should be modified using modifier 25 with the 99205 CPT code for separate reimbursement. 

For example: New patient, 70 year old male comes in to the outpatient with a head injury. The physician examines the laceration on the scalp and repairs with intermediate sutures. During the examination, there is an abrupt change in the neurological status of patient with vomiting. The physician orders immediate admission. 

The visit involves minor procedure of laceration repair and distinct evaluation and decision making for the neurological status. This qualifies the visit to be billed as 99205 CPT with Modifier 25 to receive the payment for wound repair and the E&M service.

Examples

The 99205 CPT code can be billed for the examples underneath.

Example 1

A 65 year old female new patient, comes in after a fall, with severe pain in left hip region. Patient is a smoker and diabetes, has venous insufficiency and chronic edema of both legs with redness. Physician orders X ray of hip and interprets the finding as communited fracture of the neck of femur.

Physician plan immediate hospitalization. Physician also discusses with the patient on smoking cessation, glycemic target adherence, the importance of elevating his leg to decrease edema, wearing compression stockings for venous insufficiency and the risks of pulmonary embolus for 65 minutes

Answer: CPT 99205 as the discussion and counselling dominates the high risk visit

Example 2

Initial office visit for a patient with disseminated lupus erythematosus with kidney disease, edema, purpura, and scarring lesions on the extremities plus cardiac symptoms. (Dermatology/General Surgery/Internal Medicine)

Example 3

Initial office visit for a 25-years-old female with systemic lupus erythematosus, fever, seizures, and profound thrombocytopenia. (Rheumatology/Allergy & Immunology) 

Example 4

Initial office visit for an adult with multiple cutaneous blisters, denuded secondarily infected ulcerations, oral lesions, weight loss, and increasing weakness refractory to high does corticosteroid. Initiation of new immunosuppressive therapy. (Dermatology)

Example 5

Initial office visit for a 28-years-old male with systemic vasculitis and compromised circulation to the limbs. (Rheumatology)

Example 6

Initial office visit for a 41-years-old female new to the area requesting rheumatologic care, no disability due to scleroderma and recent hospitalization for malignant hypertension. (Rheumatology)

Example 7

Initial office visit for a 52-years-old female with acute four extremity weakness and shortness of breath one weak post-fly vaccination. (Physical Medicine & Rehabilitation)

Example 8

Initial office visit for a 60-years-old male previous back surgery; now presents with back and pelvic pain, two-month history of bilateral progressive calf and thigh tightness and weakness when walking, causing several falls. (Orthopaedic Surgery)

Example 9

Initial office visit for an adolescent referred from emergency room after making suicide gesture. (Psychiatry)

Example 10

Initial Office visit for a 49-years-old female with a history of headaches and dependence on opioids, She reports weight loss, progressive headache, and depression. (Psychiatry)

Example 11

Initial office visit for a 50-years-old female with symptoms of rash, swelling, recurrent arthritic complaints, and diarrhea and lymphadenopathy, Patient has had a 25 lb weight loss and was recently camping in the Amazon. (Allergy & Immunology)

Example 12

Initial office visit for a 34-years-old uremic Type I diabetic patient referred for ESRD modality assessment and planning. (Nephrology)

Example 13

Initial office visit for a 75-years-old female with neck and bilateral shoulder pain, brisk deep tendon reflexes, and stress incontinence. (Physical Medicine & Rehabilitation)

Example 14

Initial office visit for an 8-years-old male with cerebral palsy and spastic quadriparesis. (Physical Medicine & Rehabilitation)         

Example 15

Initial office visit for a 73-years-old male with known prostate malignancy, who presents with sever back pain and a recent onset of lower extremity weakness. (Physical Medicine & Rehabilitation)

Example 16

Initial office visit for a 38-years-old male with paranoid delusions and a history of alcohol abuse. (Psychiatry)

Example 17

Initial office visit for a 12-weak-old with bilateral hip dislocations and bilateral club feet. (Orthopaedic Surgery)

Example 18

Initial office visit for a 29-years-old female with acute orbital congestion, eyelid retraction, and bilateral visual loss from optic neuropathy. (Ophthalmology)

Example 19

Initial office visit for a 70-years-old diabetic patient with progressive visual field loss, advanced optic disc cupping, and neovascularization of retina. (Ophthalmology)

Example 20

Initial office visit for a newly diagnosed Type I diabetic patient. (Endocrinology)

Example 21

Initial office evaluation of a 65-years-old female with exertional chest pain, intermittent claudication, syncope, and a murmur of aortic stenosis. (Cardiology)

Example 22

Initial office visit for a 73-years-old male with an unexplained 20 lb weight loss. (Hematology/Oncology)

Example 23

Initial office evaluation, patient with systemic lupus erythematosus, fever, seizures, and profound thrombodytopenia. (Allergy & Immunology/Internal Medicine/Rheumatology)

Example 24

Initial office evaluation and management of patient with systemic vasculitis and compromised circulation to the limbs. (Rheumatology)

Example 25

Initial office visit for a 24-year-old homosexual male who has a fever, a cough, and shortness of breath. (Infection Disease)

Example 26

Initial outpatient evaluation of a 69-years-old male with sever chronic obstructive pulmonary disease, congestive heart failure, and hypertension. (family Medicine)

Example 27

Initial office visit for a 17-years-old female, who is having school problems and has told a friend that she is considering suicide, The patient and her family are consulted in regard to treatment options. (Psychiatry)   

Example 28

Initial office visit for a female with severe hirsutism, amenorrhea, weight loss, and a desire to have children. (Endocrinology/Obstetrics & Gynecology)       

Example 29

Initial office visit for a 42-year-old male on hypertensive medication, newly arrived to the area, with diastolic blood pressure of 110, history of recurrent calculi, episodic headaches, intermittent chest pain, and orthopnea. (Internal Medicine)

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