Office o/p new hi 60 min
CPT code 99205 is used when a doctor sees a new patient in the office for a highly complex medical problem that requires extensive evaluation and typically 60-74 minutes of total visit time.
This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.
RVU breakdown
Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High
NCCI bundling edits
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Billing tips
Use time-based billing when total time reaches 60-74 minutes. Document start/stop times and all non-face-to-face activities on date of encounter (chart review, care coordination, ordering).
Impact: Time-based billing is often easier to document and defend than MDM; can justify 99205 when MDM alone might support only 99204, capturing additional $45-60 per visit
For MDM-based billing, ensure documentation shows high-level complexity with at least 2 of 3 elements: extensive number/complexity of problems (1 chronic illness with severe exacerbation/progression/side effects), extensive data review (independent interpretation of tests, discussion with external provider), or high risk (drug therapy requiring intensive monitoring).
Impact: Proper MDM documentation prevents downcoding from 99205 to 99204, protecting $40-50 per encounter
Verify patient is truly 'new' (no professional services from same physician or same specialty in same group within past 3 years). If patient seen within 3 years, must use established patient codes 99211-99215.
Impact: Billing 99205 for established patient results in denial and rebilling at 99215 rate ($175-195), losing $20-40 per visit plus administrative costs
Bill non-facility rate ($215.75) for office settings; facility rate ($175.64) applies only to hospital outpatient departments, resulting in $40.11 difference.
Impact: Ensure correct place of service code (11 for office, 22 for hospital outpatient) to receive proper payment; incorrect POS causes automatic rate adjustment
When billing 99205 with modifier 25 on same day as procedure, ensure E/M documentation clearly shows separate medical necessity beyond procedure indication. Use separate paragraphs or sections.
Impact: Clear separation prevents modifier 25 denials which require appeals; successful appeals recover full $215.75 but delay payment 30-90 days
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