For new patients in outpatient and office settings, CPT 99205 is the highest-level Evaluation and Management (E/M) code. According to current CMS and AMA rules, the right way to use 99205 depends on either high-complexity medical decision making (MDM) or at least 60 minutes of total provider time spent on the date of service. Unlike older E/M rules, documentation no longer depends on counting the elements of a history or an exam. Instead, providers must clearly show that the service is medically necessary, complicated, risky, and time-consuming. Medicare is especially likely to down-code, deny, or audit when documentation is not done correctly. This guide goes over the steps needed for 99205 documentation, explains what CMS expects, points out common mistakes, and gives real-world examples. It also talks about how professional medical billing companies like A2Z Billings help make sure that everything is done right, lower the number of denials, and protect revenue for high-value E/M services.
Understanding CPT Code 99205
When a provider does a full and complicated evaluation for a new patient in an office or outpatient setting, they use CPT 99205. This code is for visits that need a lot of clinical judgment, time, and risk management.
CMS defines 99205 as a visit that includes:
- A medically appropriate history and/or examination, and
- Either high-level medical decision making or 60 minutes or more of total provider time on the encounter date.
This code is typically billed during visits involving serious conditions, diagnostic uncertainty, multiple comorbidities, or intensive care planning.
What CMS Means by “New Patient”
Under CMS rules, the patient must be a new patient before billing 99205. A new patient is someone who hasn’t seen the same doctor or group (in the same specialty) for professional services in the last three years.
The paperwork should make it clear that the patient is new. If you don’t set this up, the system will automatically down-code to an established patient E/M code.
Best practice: Clearly state new patient status in the note to avoid payer confusion or audit risk.
Key Changes in CMS E/M Documentation Guidelines
CMS significantly revised E/M documentation guidelines to reduce administrative burden and emphasize clinical relevance over checkbox documentation.
History and Exam Are No Longer the Drivers
Under current rules, history and physical exams do not determine the E/M level. They must be medically appropriate, but the level of service is selected based on:
- Medical Decision Making (MDM),
- Total time spent by the provider
This change allows clinicians to focus on patient care instead of rigid documentation formulas.
Medical Decision Making (MDM) Requirements for 99205
High-complexity MDM is one of the two primary pathways for billing CPT 99205. CMS evaluates MDM using three distinct components, all of which must support a high level of complexity.
1. Number and Complexity of Problems Addressed
Patients with 99205 usually have one or more severe, life-threatening, or unstable conditions, or
- Many complicated problems that need a lot of testing
- Some examples are suspected cancer, uncontrolled long-term illness with complications, or symptoms that haven’t been diagnosed but pose a serious risk.
Not only should the diagnosis be listed, but the documentation should also explain why the condition is complicated.
2. Amount and Complexity of Data Reviewed
High-level MDM requires extensive data analysis, such as:
- Reviewing multiple labs or imaging studies
- Interpreting diagnostic tests
- Reviewing external medical records
- Discussing results with other healthcare professionals
The provider should document what was reviewed and why it mattered clinically.
3. Risk of Complications or Morbidity
The risk element often determines whether 99205 is justified. High risk may include:
- Decisions regarding hospitalization
- Prescription drug management with high-risk medications
- Decisions involving significant morbidity or mortality
CMS expects providers to clearly document risk assessment and clinical reasoning, not just outcomes.
Time-Based Billing for CPT 99205
When high-complexity MDM is difficult to prove, time becomes the strongest support for 99205.
To bill 99205 using time, the provider must spend at least 60 minutes on the same calendar day as the encounter. CMS allows inclusion of both face-to-face and non-face-to-face time, including:
- Reviewing medical records
- Performing the evaluation
- Counseling the patient
- Coordinating care
- Documenting the encounter
Only physician/NP/PA time counts—staff time does not qualify.
How to Properly Document Time
Time documentation must be clear, specific, and defensible. Vague statements like “spent over an hour” are risky.
Recommended approach:
- Document total minutes
- Break down major activities
- Specify that time occurred on the same date
Example:
“Total provider time: 68 minutes, including record review, patient evaluation, care coordination, and documentation.”
History Documentation Under CMS Guidelines
While history no longer determines code selection, it must still be clinically relevant and complete enough to support medical necessity.
Your documentation should include:
- Chief complaint
- Relevant HPI details
- Pertinent medical, surgical, family, and social history
Avoid copying large templates. CMS prefers concise, problem-focused narratives that support decision-making.
Examination Documentation Expectations
The physical exam should be medically appropriate and aligned with the presenting problem.
CMS does not require a comprehensive multi-system exam. Instead, document findings that:
- Support diagnostic reasoning
- Relate to the complexity of care
- Justify testing or treatment decisions
Quality matters more than quantity.
Assessment and Plan: The Backbone of 99205
The assessment and plan section often determines whether 99205 survives an audit.
A strong plan should:
- Address each problem evaluated
- Explain diagnostic and treatment decisions
- Outline follow-up, referrals, and risk mitigation
CMS auditors look for clinical logic, not generic statements.
Common Documentation Errors That Trigger Denials
Despite correct care delivery, many 99205 claims are denied due to documentation issues.
Frequent Mistakes Include
- Billing 99205 without meeting MDM or time thresholds
- Poorly documented time
- Vague risk statements
- Copy-paste notes without individualized detail
- Avoiding these errors significantly improves reimbursement success.
Audit Risk and Compliance Considerations
Because 99205 is a high-reimbursement code, it is frequently targeted for audits—especially by Medicare.
stay compliant:
- Ensure documentation supports medical necessity
- Align diagnosis severity with MDM
- Maintain consistency across notes, claims, and coding
Routine internal audits are highly recommended.
How A2Z Billings Supports 99205 Compliance
Proper documentation alone does not guarantee payment. Accurate coding, claim submission, and denial management are equally critical.
- Before sending in claims, A2Z Billings checks the provider’s paperwork to make sure it meets all CMS requirements for 99205.
- Claims are sent in with the right modifiers, diagnosis links, and supporting data, which makes it less likely that the payer will reject them.
- If a payer down-codes or denies a 99205 claim, A2Z Billings uses documentation strategies that are in line with CMS to handle appeals.
- A2Z Billings helps practices get the most money back by keeping an eye on denial trends and how payers act.
Conclusion
CPT 99205This code is very helpful in documenting the amount of time, decision-making and complexity characteristic of higher level new patient visits. In current CMS regulations, the criteria for successful billing of 99205 include documented high-complexity medical decision making or at least 60 minutes of total provider time as well as a medically appropriate history, examination and reasonable assessment and plan. With Medicare, private insurers scrutinizing high-value E/M codes [unfinished] Unfinished or unclear documentation can easily lead to denials, down-coded claims or audits.
Make An Appintment With A2Z5 Frequently Asked Questions (FAQs)
Yes. If 60 minutes or more of total provider time is documented, 99205 can be billed even without high MDM.
No. CMS asks for a medically necessary exam, not an exhaustive one.
No. Only the time of the provider counts for time billing.
Most down-coding occurs due to insufficient documentation of MDM, risk, or time.
By using structured documentation, time tracking, internal audits, and professional billing support like A2Z Billings.