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CPT Code 99205 – Real Insights into High-Level E/M Visits

A women inside the LCDs search about the CPT Code 99205 for the medical billing process.

When you’re billing for new patient appointments at the highest complexity, CPT Code 99205 is the go-to code. But using it correctly can feel overwhelming. At Express Medical Billing, we’ve worked hands-on with providers navigating the detailed requirements of 99205 and we’re here to break it down with clarity, empathy, and first-hand experience.

What Is CPT Code 99205 Used For?

CPT Code 99205 is an Evaluation and Management (E/M) code for new patients seen in an office or outpatient setting. It represents the most difficult level of new patient care. Typically, it’s used when:

  • The visit involves high medical decision-making
  • A complete history and checkup are performed
  • The time spent is 60–74 minutes with the patient and/or family

Providers who manage patients with multiple chronic conditions, psychiatric needs, or complex diagnostic discussions often find themselves needing to bill 99205.

CPT Code 99205 Definition & Requirements

To code 99205 correctly, documentation must reflect:

  • A comprehensive history
  • A comprehensive physical exam
  • High-complexity medical decision-making (MDM)
    OR a visit that lasts 60–74 minutes total (face-to-face or via telehealth when applicable)

And yes, documentation must match this level. At Express Medical Billing, we’ve seen denials occur when just one required element is missing.

CPT Code 99205 Times Spent & Description

According to the AMA’s 2025 E&M coding guidelines, time can now be the sole determining factor if 60–74 minutes are spent on the date of service. This includes:

  • Reviewing patient records
  • Ordering/ reviewing tests
  • Counseling and education
  • Coordinating care with other professionals

Real Example: A neurologist we support spent 70 minutes managing a new patient’s stroke follow-up and counseling their family—99205 was the perfect fit.

CPT Code 99205 Reimbursement in 2025

This code is highly reimbursed due to its complexity. On average:

  • Medicare reimbursement: ~$238 (varies by locality)
  • Commercial insurance: Can range from $250–$350

But accurate reimbursement depends on clear documentation, proper modifiers, and choosing the right code between 99204 and 99205.

CPT Code 99205 Reimbursement in 2025

This code is highly reimbursed due to its complexity. On average:

  • Medicare reimbursement: ~$238 (varies by locality)
  • Commercial insurance: Can range from $250–$350

But accurate reimbursement depends on clear documentation, proper modifiers, and choosing the right code between 99204 and 99205.

CPT Code 99205 Modifiers - 25 & 95

  • Modifier 25: Used when 99205 is billed with another service, like a procedure (e.g., vaccine or injection).
  • Modifier 95: Needed when 99205 is used via telehealth.

Pro Tip: Improper use of modifiers is a top reason for denials. Our billing experts audit documentation before claims go out saving time and maximizing revenue.

How CPT Code 99205 consist to Other E/M Codes

CPT Code

 Patient Type

Time

Complexity

99204

 New

45–59 mins

Moderate

99205                     

New                                          

60–74 mins                             

High

99215

Established

40–54 mins

High

99238

Hospital Discharge

<30 mins

Moderate

99291

Critical Care

30–74 mins

Critical care

If you’re comparing codes like 99204 vs. 99205, always look at time spent and MDM level. Overbilling leads to audits; under billing leaves money on the table.

Does Medicare Cover CPT Code 99205?

Yes, Medicare covers 99205, but it requires:

  • The correct E/M documentation
  • Any applicable modifiers
  • A medically necessary reason for a high-level service

As Medicare audits have tightened in 2025, accurate use of 99205 has become even more critical.

Office Visit or Hospital Follow-Up?

99205 is used in office/outpatient settings. For hospital follow-ups, codes like 99231–99233 are more appropriate. For hospital discharge, use CPT 99238 or 99239 depending on time spent

First-Hand Billing Insight

At Express Medical Billing, one of our clients a psychiatric practice frequently uses 99205 for complex first visits. Many of these patients require coordination with family, deep psychological evaluation, and care planning.

Using 99205 has improved their revenue cycle without increasing claim denials because we ensured compliance with documentation standards.

CPT Code 99205 - Key Takeaways

  • Use it for new patient visits requiring high-complexity decision-making or 60–74 minutes of time
  • Requires comprehensive documentation
  • Ensure correct use of modifiers 25 or 95 when needed
  • Verify payer policies, especially for Medicare
  • Compare with codes like 99204, 99215, 99238, and 99291 before billing

Final Thoughts

Using CPT Code 99205 properly isn’t just about compliance it’s about fair reimbursement for complex, meaningful care. At Express Medical Billing, we bring human insight and deep coding expertise to ensure your claims are accurate, audit-proof, and profitable.

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Frequently Asked Questions (FAQs)

CPT Code 99205 is used for new patient office or outpatient visits that require high-complexity medical decision-making or 60–74 minutes of total physician time on the date of service.

It describes a high-level, comprehensive evaluation of a new patient that includes detailed history, exam, and complex decision-making, or a visit lasting 60–74 minutes.

The 2025 time requirement is 60 to 74 minutes of total time spent by the provider on the date of the encounter. This includes documentation, reviewing records, and care coordination.

In 2025, Medicare typically reimburses around $238 for 99205. Private insurers may pay $250 to $350, depending on the provider’s location and contract rates.

Yes, in some cases:

  • Use Modifier 25 when a procedure is done on the same day.
  • Use Modifier 95 for telehealth encounters.

Yes, Medicare covers 99205, provided the documentation meets the criteria and the service is medically necessary.

Yes. As of 2025, 99205 can be billed for telehealth with Modifier 95, as long as all requirements are met.

Yes. As of 2025, 99205 can be billed for telehealth with Modifier 95, as long as all requirements are met.

  • 99204: Moderate complexity, 45–59 minutes
  • 99205: High complexity, 60–74 minutes

The choice depends on time and the complexity of decision-making.

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