E/M New · CMS status A
99205
Office o/p new hi 60 min
Office or other outpatient visit, new patient, high-level medical decision making OR 60-74 minutes of total time on the date of the encounter. The CMS 2026 wRVU for 99205 is 3.50. Reserved for high-acuity new-patient encounters.
Work RVU
3.50
2026 Medicare pays
$236.81
National GPCI · non-facility · CF $33.4009
RVU anatomyWork 3.50 + Practice 3.23 + Malpractice 0.36 = 7.09 total
Work (your effort)Practice expenseMalpractice
Billing guidance for 99205 is locked
- When to use it: the exact clinical situations that support billing 99205
- Documentation checklist: the 5 elements your note needs before submitting
- Common pitfalls: the 5 mistakes that get 99205 downcoded or denied
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Common modifiers
2595
Common ICD-10 pairings
C50.911I50.22E11.65I27.0K72.10
Payer notes
Medicare audits 99205 closely; the average specialty rate is around 5 to 15 percent of new-patient visits, and clinicians significantly above this draw post-payment review. For Medicare patients, use G0316 for prolonged services beyond 75 minutes. Commercial payers including UnitedHealthcare, Anthem, and Cigna accept 99417. For oncology consults, some payers require an authorized referral from the primary care provider before paying 99205.
Pairs well with
Educational reference, not billing or legal advice. Verify against your payer contracts and your compliance team before submission.