The short version
- 99205 is a level 5 office visit for a new patient. High-complexity medical decision making, or 60 to 74 minutes of total time on the date of service. Either path on its own.
- High MDM means two of three grid elements reach high. The risk column at high is a real bar — intensive drug monitoring, major surgery decisions, hospitalization. Prescription management alone does not get you there.
- 2026 Medicare pays about $237 nationally for 99205, non-facility, against a conversion factor of $33.40 for non-QP clinicians and $33.57 for QPs.
- Past 74 minutes, Medicare pays G2212, not 99417. 99417 carries status I in the 2026 fee schedule, which means Medicare does not pay it at all. And G2212 does not start until 89 minutes.
- Office visits were exempt from the 2026 efficiency adjustment. The work RVU for 99205 is unchanged at 3.50.
What 99205 actually requires in 2026
History and exam do not determine the level. You document them as medically appropriate and they carry no scoring weight. What sets the level is medical decision making or total time, the same as every other new patient code.
By MDM, 99205 is high complexity, and high is a genuinely high bar. The next section walks it.
By time, 99205 is 60 to 74 minutes of total time on the date of service — chart review before the visit, the visit itself, and the note, all on that day. Staff time does not count. Work you finish the next morning does not count.
Fall under 60 minutes on the time path and it is a 99204. Go past 74 and you are into prolonged services, which do not work the way most people assume.
What high MDM actually requires
Same grid as every other office visit. Three columns, two of them have to reach high.
Problems addressed. High means one or more chronic illnesses with severe exacerbation, progression, or treatment side effects; or an acute or chronic illness or injury that poses a threat to life or bodily function. Not a flare. A severe one.
Data reviewed. High means meeting two of the three data categories, not one: a combination of three items across external notes, unique tests ordered or reviewed, and an independent historian; an independent interpretation of a test someone else performed and billed; or a discussion of management with an external physician or qualified professional.
Risk. High means drug therapy requiring intensive monitoring for toxicity; a decision about elective major surgery with identified patient or procedure risk factors; a decision about emergency major surgery; a decision about hospitalization or escalating hospital-level care; or a decision to de-escalate care because of poor prognosis.
Notice what is not on that list. Prescription drug management sits at moderate. It gets you to 99204, not here. Intensive monitoring means the kind of toxicity surveillance that needs its own lab schedule, not a refill.
What 99205 pays in 2026
Medicare’s 2026 conversion factor is $33.40 for clinicians who are not qualifying APM participants and $33.57 for those who are, both effective January 1, 2026. At 7.09 non-facility RVUs, 99205 lands at about $237 nationally before locality adjustment. The same code in a facility setting pays about $160 — a practice-expense difference, not a coding one.
The 2026 efficiency adjustment cut work RVUs by 2.5% across roughly 7,700 codes and did not touch office visits. CMS exempted the time-based E/M family, 99202 through 99215, so the work RVU for 99205 is still 3.50. Separately, indirect practice expense for facility work was cut in half, which moves money toward office-based care.
| Code | Level | Time (total, date of service) | MDM | 2026 national average |
|---|---|---|---|---|
| 99202 | 2 | 15-29 min | Straightforward | ~$75 |
| 99203 | 3 | 30-44 min | Low | ~$118 |
| 99204 | 4 | 45-59 min | Moderate | ~$177 |
| 99205 | 5 | 60-74 min | High | ~$237 |
| G2212 | add-on | 89+ min (Medicare) | – | ~$34 per 15 min |
When 60 to 74 minutes is not enough
This is where 99205 claims quietly fail, because CPT and Medicare do not use the same code or the same threshold.
CPT says use 99417 for each additional 15 minutes once total time hits 75 minutes — 15 past the minimum time of 99205.
Medicare says use G2212, and only once total time exceeds the maximum time by 15 minutes. The maximum for 99205 is 74 minutes, so G2212 does not start until 89 minutes.
In the 2026 fee schedule, 99417 carries status I. Medicare does not pay it. G2212 carries status A and pays about $34. So a Medicare claim for a 78-minute new patient visit is a plain 99205 — the extra 18 minutes are not separately billable, and appending 99417 gets the line rejected, not the visit downcoded.
Most commercial payers follow CPT and take 99417 at 75 minutes. Some follow Medicare. This is worth confirming payer by payer rather than setting one rule in the encounter form, because the two rules are 14 minutes apart.
Five mistakes that turn a clean 99205 into a denial
- Billing 99417 to Medicare. It is status I. Medicare pays G2212, and not until 89 minutes.
- Treating prescription drug management as high risk. It is moderate, which is 99204.
- Meeting only one data category. High MDM needs two of the three.
- Documenting 68 minutes with a note that shows a routine visit. Time is a valid path, but the record still has to be credible.
- Billing a new patient code for someone your partner saw within three years.
Frequently asked questions
What is CPT code 99205?
A level 5 office or outpatient visit for a new patient, supported by either high-complexity medical decision making or 60 to 74 minutes of total time on the date of service. Either path qualifies on its own.
How much does 99205 pay in 2026?
About $237 nationally under Medicare, non-facility, before locality adjustment. The 2026 conversion factor is $33.40 for clinicians who are not qualifying APM participants and $33.57 for those who are, both effective January 1, 2026.
What counts as high medical decision making?
Two of three grid elements at high. Problems: a chronic illness with severe exacerbation or progression, or an illness or injury threatening life or bodily function. Data: meeting two of the three data categories. Risk: intensive drug toxicity monitoring, a decision about emergency or risk-laden elective major surgery, hospitalization, or de-escalation of care for poor prognosis.
What is the difference between 99204 and 99205?
MDM complexity and time. 99204 is moderate-complexity MDM or 45 to 59 minutes; 99205 is high-complexity MDM or 60 to 74 minutes. The payment difference is about $59 per visit.
Should I bill 99417 or G2212 with 99205?
For Medicare, G2212 — 99417 carries status I in the fee schedule and is not paid. G2212 starts only after the maximum time is exceeded by 15 minutes, meaning 89 minutes of total time. Most commercial payers follow CPT and accept 99417 starting at 75 minutes, but confirm this payer by payer.
Does prescribing medication support a 99205?
No. Prescription drug management sets the risk column at moderate, which supports 99204. High risk requires intensive monitoring for drug toxicity, a major surgery decision, hospitalization, or de-escalation of care.
Is 99205 affected by the 2026 efficiency adjustment?
No. CMS exempted time-based services, including the E/M office visit family 99202 through 99215, from the 2.5% efficiency adjustment applied to roughly 7,700 other codes in 2026. The work RVU for 99205 is unchanged at 3.50.
Can 99205 be billed with a procedure on the same day?
Yes, with modifier 25 appended to the E/M, and only when the evaluation was significant and separately identifiable from the procedure. Missing modifier 25 is one of the most common dermatology denials.
This article explains how these codes tend to get paid — it is not coding, billing, or legal advice. Some of the codes here are bundled into the main procedure, or fall into grey areas that vary by payer. Before billing anything in a grey area, confirm it with your own coding and compliance team and the current guidance from the American Academy of Dermatology (AAD), Medicare (CMS), and AMA CPT. When in doubt, don’t bill it.
