99205 CPT Code | Description, Reimbursement, Modifier & Examples
The 99205 CPT code can be reported for a new patient’s office or other outpatient visits. The estimated time is between 60 and 74 minutes. This procedure can be billed with modifier 25; the RVU has been 3.50 since 2021.
CPT Code 99205 | Description & Explanation
CPT 99205 can be billed for a new patient’s office or other outpatient visits. 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.
Description: Office or other outpatient visits for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 60-74 minutes of total time is spent on the date of the encounter.
How many minutes is the 99205 CPT code?
Procedure 99205 is estimated to be between 60 and 74 minutes. The total time needs to be spent on the date of the encounter.
If the procedure exceeds 74 minutes, bill prolonged services (CPT 99354 – CPT 99357).
Guidelines for time
Revision of time means the total time spent with the patient on the encounter date that recognizes face-to-face and crucial nonface to face activities. Precise time ranges for each code should be documented with easy-to-remember increments.
When the visit dominates counseling and/or care coordination, time should ONLY be used to select the E&M level. However, time may be used whether or not counselling and/or care coordination dominates the service.
Time could be counted for any relevant activities that are not separately reported, starting from preparation to see the patient, obtaining history & documenting in medical records, reviewing tests or history, managing the patient by the ordering of tests, medicines, or procedures performing a medically necessary examination and/or evaluation, counseling 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 the management of a patient
How many RVUs do I need for 99205?
The RVU for the 99205 CPT code has increased to 3.50 in 2021 form 3.17 in 2020.
Reimbursement
CPT 99205 will only be reimbursed if the patient is new. This procedure code means high or level 5 office visits 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 injuries 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 threatens a 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 analyzed must be extensive to bill CPT 99205. Analyzed 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 whether ACOD is 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 a physician:
- prior external note/notes;
- result/results of each unique test.
Assessment requiring an independent historian/historians.
Example: A patient unable to talk or is 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: Discussions with a 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.
Example: A new patient, a 70-year-old male patient, comes into the outpatient with a head injury. The physician examines the laceration on the scalp and repairs it 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 a minor laceration repair procedure 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 the left hip region. The patient is a smoker and diabetes, has venous insufficiency, and chronic edema of both legs with redness. The physician orders an X-ray of the hip and interprets the finding as a comminuted fracture of the neck of the femur.
Physician plan immediate hospitalization. The physician also discusses with the patient 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 counseling 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-year-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-year-old male with systemic vasculitis and compromised limb circulation. (Rheumatology)
Example 6
Initial office visit for a 41-year-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-year-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-year-old male with 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 the emergency room after making a suicide gesture. (Psychiatry)
Example 10
Initial Office visit for a 49-year-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-year-old female with symptoms of rash, swelling, recurrent arthritic complaints, diarrhea, and lymphadenopathy. The 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-year-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-year-old male with cerebral palsy and spastic quadriparesis. (Physical Medicine & Rehabilitation)
Example 15
Initial office visit for a 73-year-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-week-old with bilateral hip dislocations and bilateral club feet. (Orthopaedic Surgery)
Example 18
Initial office visit for a 29-year-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-year-old female with exertional chest pain, intermittent claudication, syncope, and a murmur of aortic stenosis. (Cardiology)
Example 22
Initial office visit for a 73-year-old male with an unexplained 20 lb weight loss. (Hematology/Oncology)
Example 23
Initial office evaluation included a patient with systemic lupus erythematosus, fever, seizures, and profound thrombodytopenia. (Allergy & Immunology/Internal Medicine/Rheumatology)
Example 24
Initial office evaluation and management of patients with systemic vasculitis and compromised limb circulation. (Rheumatology)
Example 25
Initial office visit for a 24-year-old homosexual male with a fever, cough, and shortness of breath. (Infection Disease)
Example 26
Initial outpatient evaluation of a 69-year-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)
