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.
When to use it
Use 99205 for a new patient with severe, decompensated, or high-acuity disease, or for complex consult-style new-patient encounters where decisions about hospitalization, major surgery, drug therapy requiring intensive monitoring, or de-escalation of care are made. Real examples: a new patient referred for severe pulmonary hypertension where right-heart catheterization is planned; a new oncology consult for newly-diagnosed metastatic disease where systemic therapy is initiated; a new patient with decompensated heart failure where admission is considered.
Full guidance
Time-based alternative is 60 to 74 minutes of total time on the date of the encounter. Beyond 75 minutes, add 99417 (commercial) or G0316 (Medicare) in 15-minute increments.
Documentation checklist
- ✓MDM high complexity on at least two of three elements, OR 60 to 74 minutes total time.
- ✓Document the high-risk element explicitly: hospitalization consideration, intensive monitoring required, drug toxicity risk, or major procedure decision.
- ✓Three-year rule applies (same as 99203 and 99204).
- ✓Extensive data review usually fulfills the data element: review of outside records, independent interpretation of imaging, AND discussion with another provider all combining to meet extensive criteria.
- ✓When time-based and exceeding 75 minutes total, add the appropriate prolonged-service code per payer.
Common pitfalls
- !Inflating new-patient complexity without supporting MDM elements. High-MDM requires a real high-risk element, not just a sick patient.
- !Skipping G2211 on high-complexity new patients in continuity care. Even high-acuity new-patient visits are eligible if continuity is intended.
- !Billing 99417 when Medicare is the payer. Medicare requires G0316 for outpatient prolonged services; 99417 will be denied.
- !Not capturing the decision regarding hospitalization element when it occurred. A one-line note ("considered inpatient admission for IV diuresis, elected outpatient management with same-day stress testing") satisfies the requirement.
- !Failing to document discussion with another provider when that discussion was part of the data element. Document who you called and what was discussed.
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.