Office or other outpatient visit, new patient, level 5
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Insufficient documentation to support level 5 new patient complexity
Very Common99205 (level 5 new patient visit) requires high complexity medical decision-making OR 60-74 minutes total time. Most denials occur when documentation shows moderate complexity problems or time not documented. Payers downgrade to 99204 or 99203, reducing reimbursement by $50-$120. 99205 represents only 8-12% of new patient visits - significant scrutiny when billed.
Common Causes
- • MDM documented as moderate complexity, not high (requires 3+ chronic conditions OR prescription drug management with risk)
- • Total time documented as 45-50 minutes (99204 range), not 60-74 minutes required for 99205
- • New problem evaluated but not high-risk (stable chronic disease follow-up doesn't qualify)
Resolution Strategy
For MDM-based denials: Document high complexity required elements: 3+ chronic conditions with exacerbation/progression/side effects requiring prescription drug management, OR 1+ chronic illness with severe exacerbation requiring hospitalization consideration, OR acute illness with systemic symptoms and high risk of morbidity without treatment. For time-based denials: Add explicit total time statement ('Total encounter time: 65 minutes') with start/stop times if possible. Appeal with enhanced documentation within 60 days. Success rate 40-60% if legitimate high complexity present.
2. Billed as new patient but previous visit within 3 years
Common99205 denied when patient seen by same physician or same-specialty physician in group practice within previous 36 months. Should be billed as established patient 99215. The 3-year rule applies practice-wide for same specialty - patient can't be 'new' just because different doctor in group.
Common Causes
- • Patient seen 2.5 years ago by partner physician in practice
- • Previous visit was telehealth or hospital consult - still counts as established
- • Patient changed insurance but was seen within 3 years
Resolution Strategy
Verify patient's last visit date with any same-specialty provider in group. If truly >36 months, appeal with documentation. If <36 months, rebill as established patient 99215. Cannot win appeal if patient seen within 3 years by same specialty.
💬 Plain Language Explanation
What this means
This is the most complex new patient office visit. Your doctor performed a comprehensive examination, spent significant time with you, and made highly complex medical decisions.
Why you might see this
This is the highest level of new patient visit. You might see this if you had multiple serious health concerns, needed extensive evaluation, or required complex treatment planning during your first visit.
Common context
Used for new patients with highly complex medical issues, multiple serious concerns, or extensive evaluation needs.
What to ask your provider
"'This is the highest level new patient visit code. Can you explain what made this visit so complex that it required this level of service?'"
Relative Value Units (RVUs)
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Clinical Information
When to Use
New patient visit with high complexity medical decision-making or 60-74 minutes total time
Common Scenarios
Documentation Requirements
- Comprehensive history with extensive detail
- Comprehensive examination (8+ organ systems detailed)
- High complexity medical decision-making
- OR document 60-74 minutes total time with detailed activities
Coding Guidelines
Common Modifiers
Bundling Rules
- High level requires clear justification in documentation
- Subject to increased audit scrutiny
Exclusions
- Do not use for established patients (use 99215)
- Do not use if time <60 minutes (use 99204)
Coding Notes
Clinical scenarios
- Comprehensive history with extensive detail
- Comprehensive examination (8+ organ systems detailed)
- High complexity medical decision-making
- Comprehensive history with extensive detail
- Comprehensive examination (8+ organ systems detailed)
- High complexity medical decision-making
- Comprehensive history with extensive detail
- Comprehensive examination (8+ organ systems detailed)
- High complexity medical decision-making
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Frequently Asked Questions
CPT 99205 is the billing code for "Office or other outpatient visit, new patient, level 5". New patient visit with high complexity medical decision-making or 60-74 minutes total time
Medicare pays approximately $215.75 for CPT 99205 (national average). Actual payment varies by geographic location due to GPCI adjustments. Hospital and commercial insurance rates are typically 2-4x higher than Medicare rates.
CPT 99205 has a total RVU of 6.29, broken down as: Work RVU 3.50, Practice Expense RVU 2.55, and Malpractice RVU 0.24. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 99205 is "Insufficient documentation to support level 5 new patient complexity". 99205 (level 5 new patient visit) requires high complexity medical decision-making OR 60-74 minutes total time. Most denials occur when documentation shows moderate complexity problems or time not documented. Payers downgrade to 99204 or 99203, reducing reimbursement by $50-$120. 99205 represents only 8-12% of new patient visits - significant scrutiny when billed. Common causes include: MDM documented as moderate complexity, not high (requires 3+ chronic conditions OR prescription drug management with risk); Total time documented as 45-50 minutes (99204 range), not 60-74 minutes required for 99205. Appeal success rate is approximately 40-60%.
Key documentation requirements for CPT 99205 include: Comprehensive history with extensive detail; Comprehensive examination (8+ organ systems detailed); High complexity medical decision-making; OR document 60-74 minutes total time with detailed activities. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 99205: High level requires clear justification in documentation. Subject to increased audit scrutiny Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 99205 include: 25 (When E/M separate from same-day procedure). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 99205 is 60-74 minutes total time on date of service. Time-based codes require documentation of the actual time spent providing the service.