CPT Code 99205: Optimizing Your Practice’s Billing in 2024

March 25, 2024

CPT Code 99205: Optimizing Your Practice’s Billing in 2024

CPT code 99205 is used for new patient or outpatient visits that require a high complexity of medical decision-making and/or 60+ minutes of encounter time, providing clinics with a higher reimbursement rate than lower-level codes such as CPT code 99204.

We’ll check out everything you need to know about CPT code 99205, including what it is, what level of care it is, and its reimbursement rates. 

And here’s a bonus tip: we specialize in getting your clinic the most amount of revenue by taking care of all your medical coding, so send us a quick message if you want to forget about this stuff completely and focus all your time on your patients!


Key Points:

  • CPT code 99205 is used for new patient office or outpatient visits that require comprehensive evaluation, high complexity in medical decision-making, or 60-74 minutes of patient encounter time.
  • Accurate documentation and code selection are essential for maximizing reimbursement with CPT code 99205.
  • Choosing code 99205 when possible offers higher reimbursement rates than codes such as 99204 and 99203 – undercoding is making you lose out on money!

What is CPT Code 99205?

CPT code 99205 is indicated for an office or outpatient visit that involves the assessment and management of a new patient, requiring a high complexity of medical decision-making (MDM).

You can code based on MDM or time thanks to the changes to E/M coding in 2021, which took out the requirements of typical face-to-face patient visits.

A single encounter of 60-74 minutes of total time on the visit date is required to code 99205.

CPT Code 99205 Description: New patient visits requiring comprehensive evaluation, high complexity medical decision-making, and 60-74 minutes of encounter time.

What Level of Care is 99205?

CPT code 99205 is a level 5 of care, representing the pinnacle of outpatient/office visit codes for new patients. 

This means that code 99205 typically involves a meticulous patient evaluation and care plan, with the highest level of MDM possible.

Therefore, it surpasses the requirements of lower-level codes like 99204 (more on that in a bit).

Why You Need To Bill CPT Code 99205 

You leave a lot of money on the table if you don’t properly use CPT code 99205. 

For example, you may undercode and use code 99204 when you could (and should) actually be using 99205, cutting down the reimbursement you’re getting…

This isn’t a new issue – many clinicians face struggles with accurately coding, especially at higher levels. That’s why we’re so proud of our services that help you maximize your profits and allow you to spend more time with your patients!

CPT Code 99205 Requirements

Codes like 99205 required three key components: medical decision-making, a medical history, and a detailed examination of the patient. 

Recent changes emphasize MDM and/or total time spent with the patient, affecting this and other codes like 99214 and 99205 – basically, your code selection is based on MDM level or total time spent with the patient on date of encounter.

Criteria for coding 99205 in 2024 focuses on:

  • High level of medical decision-making
  • 60-74 minutes of patient visit time
  • Medically appropriate history/examination

Coding CPT Code 99205 For Time

CPT code 99205 can be selected for new patient visits lasting 60+ minutes on the date of encounter. 

Coding for time makes it much easier to code in the higher levels, which is important because in those same revisions that made coding at higher levels easier, reimbursement for professional practices were slashed by 11%!

So, get all the codes you can!

99205 CPT Code Reimbursement Rates in 2024

The Medicare reimbursement rate for CPT code 99205 in 2024 is $216.77.

The high value represents the complexity of the patient visit, and is significantly greater than the reimbursement rate for CPT code 99204, for example, which is $164.38 from Medicare.

Common Mistakes to Avoid in Billing CPT Code 99205

Get that cash by avoiding these common mistakes:

  • Overcoding & Undercoding: The visit needs to match the requirements for each specific code, so stay documented!
  • Mixing-Up Patient Status: CPT code 99205 is for new patients, so don’t get it mixed up with established patient codes!
  • Not Documenting Time: Encounter time is a way you can code CPT code 99205, so keep track of how long you’re spending with your patient. 

Stay ahead by keeping detailed documentation, staying up to date with the latest billing practices, and analyzing where you’re going wrong and hemorrhaging cash.

CPT Code 99203 vs. 99204 vs. 99205

Other new patient codes like 99203 and 99204 are often used instead of 99205 by fear of overcoding or simply not knowing the difference. 

Here is a quick chart explaining the differences between them:

CodeHistory/ExamMDMEncounter Time (minutes)Reimbursement Rate (2024)
99202Medically appropriate history and/or examinationStraightforward15-29$71.06
99203Medically appropriate history and/or examinationLow30-44$109.69
99204Medically appropriate history and/or examinationModerate45-59$164.38
99205Medically appropriate history and/or examinationHigh60-74$216.77
From AAPC

Conclusion

Navigating the complexities of CPT code 99205 is not easy, and requires you to constantly stay on top of things.

Maximizing revenue is all about getting all the codes you deserve, with 99205 being a big (and profitable) one. 

We specialize in medical billing and coding, and would love to take it off your hands – so you get paid and spend more time with your patients, doing what you love!

FAQs

What type of exam is required for a 99205?

A medically appropriate history and/or examination that requires high medical decision-making.

What is the rate for CPT code 99205?

The Medicare reimbursement rate for CPT code 99205 in 2024 is $216.77.

What is the difference between 99203, 99204, and 99205?

The primary differences lie in the complexity of medical decision-making and the required time, with 99205 indicating the highest complexity and longest encounter time.

What is the CPT code for a new patient visit?

New patient visits are covered by codes 99201-99205, with the specific code chosen based on the complexity of the visit.

What is an example of a 99205 patient?

A new patient presenting with complex, multi-system issues that require an in-depth evaluation and high complexity in medical decision-making.

What is the difference between code 99205 and 99204?

Code 99205 is used for the most complex new patient visits, requiring comprehensive evaluation and high complexity in decision-making, a step above the complexity of 99204.

What modifier is needed for 99205?

Modifiers depend on specific billing circumstances. For instance, -25 might be used if a significant, separately identifiable service is provided on the same day.

Can 99205 and another code be billed together?

It depends on the services provided and payer rules. Proper use of modifiers and adherence to billing guidelines are essential when billing multiple services.

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