When it comes to mastering CPT Codes, 99205 CPT Code is one of the most important medical billing codes. 

So, it’s one of the most important codes that every healthcare organization or clinic must know to use accurately during the medical billing and reimbursement processes.

In this article, we will understand everything about the 99205 CPT, its importance, billing guidelines, requirements, criteria, and mistakes to avoid. By the end of this article, you’ll be a master of 99205 CPT Code.

So, without any further delay, let’s begin!

What is CPT Code 99205?

99205 CPT Code is a high-level evaluation and management code that is used for new patient visits for both office and outpatient visits. This code is especially used for those new patients who require 60-74 minutes face-to-face on the visit date because they have complex medical issues and require a comprehensive evaluation with high-level decision-making.

What Level of Care is 99205?

It has required Level-5 care, which represents the highest level of care for new patients in outpatients/office visits. It means that doctors need to perform a very detailed patient evaluation with a high level of decision-making. It suppresses the requirements of lower CPT codes like 99204.

CPT Code 99205 Billing Guidelines

When billing the CPT Code 99205 then there are some key rules to follow:

1. High Level of Decision-Making

This code is used when doctors need to handle complex medical issues of patients, which may involve multiple tests, reviewing medical records, and creating personalized diagnoses and treatment plans by spending most of their time with patients.

2. Comprehensive History or Exam

The doctor needs to conduct a detailed review of the patient’s medical history, identify symptoms, and get past treatment records to understand the patient’s current condition fully.

3. Session Length

A typical visit of new patients for complex medical issues lasts between 60-74 minutes, including face-to-face time and 99205 time spent reviewing their cases.

In short, CPT 99205 is used for new patients who have complex issues that require 60-74 minute visits for proper documentation, decision-making, and treatment plans. 

Example of CPT Code 99205 Billing Guidelines:

Criteria	Requirements
Medical Decision-Making Complexity	High complexity
History or Examination	Comprehensive
Session Length	60-74 minutes

Why Do You Need To Bill CPT Code 99205?

The reason behind billing is that it’s the most advanced level of patient care, and if healthcare organizations and clinics are not using it, then they lose significant revenue during the reimbursement process. That’s why it’s important to know the right code for the right medical services, especially for complex visits, to get full reimbursement for your work.

CPT Code 99205 Documentation Requirements

When you’re billing for CPT 99205 then there are some specific documentation required:

1. High-level Medical Decision-Making

When a doctor is evaluating and managing a complex medical patient,  then they must think carefully and make complex decisions. This can be done only after analyzing medical records, test results, and other important details to diagnose and create a personalized treatment plan for the painter. 

2. Comprehensive Medical History or Examination

To understand a patient’s medical condition, doctors need to collect a detailed medical history of the patient and do a detailed examination, which includes asking about the patient’s medical background, symptoms, previous treatments, and any other medical-related documents.

3. Session Duration Ranging from 60-74 minutes

When you’re billing the 99205, it usually lasts between 60-74 minutes, which means a doctor spends this time during a patient visit that includes both face-to-face visits and time for examining medical history.

Coding CPT Code 99205 For Time

CPT 99205 is useful for new patients who visit 60-74 minutes on the date of encounter. This 99205 time spent indicates the high level of medical complexity that doctors handle and makes reimbursement easier to process.

Here’s the breakdown of time length for complex medical visit:

Component	Time Spent (minutes)
Comprehensive History	15
Comprehensive Examination	20
Medical Decision-Making	25
Coordination of Care	10
Total Time =	70

CPT Code 99205 Reimbursement Rates in 2024

The medicare reimbursement rate of 99205 Code is $220.36. It’s a high value that represents the medical complexity of the patient as compared to other CPT codes like 99204, which is around $167.10.

Common Mistakes to Avoid in Billing CPT Code 99205

Here are some common mistakes that professionals made while billing for 99205 CPT:

1. Not Enough Documentation

A common mistake that professionals make during medical billing of the 99205 CPT Code description is not having enough documents to support this billing. As this is a high-level medical code, it requires a detailed patient’s medical history, examination, and notes for making high-level decisions and treatment plans for patients.

2. Overbilling

When you bill for a service that is too high compared to the actual visit, then it goes to an audit. So make sure you’ve notes that reflect the complexity of medical visits during the audits and prove the billing.

3. Lack of Medical Necessity

You always need to make sure that the care you provide to the patients is necessary. So that it ensured that the level of service provided was needed and helped ensure reimbursement.

4. Undercoding

Ensure that the documents you provided justify the complexity of the patient visit to get the proper reimbursement. Sometimes, professionals provide lower service level billing for the high-level service.

5. Not Documenting Time

Time is one of the crucial factors that determine the complexity of medical services. 99205 CPT Code description required a long visit, around 60-74 minutes, with counseling or coordinating care. You need to document the time; otherwise, reimbursement can be denied.

6. Mixing Up Patient Status

This code is only used for new patient visits. So, make sure not to sue established patients, and this can lead to billing issues.

By avoiding these mistakes, you can accurately bill for complex medical services and use the code to get the proper reimbursement.

CPT Code 99203 vs. 99204 vs. 99205

Here’s a quick comparison between CPT Code 99203 vs. 99204 vs. 99205 to know the difference between them:

Code	History/Exam	MDM	Encounter Time (minutes)	Reimbursement Rate (2024)
99202	Medically appropriate history and/or examination	Straightforward	15-29	$72.23
99203	Medically appropriate history and/or examination	Low	30-44	$111.51
99204	Medically appropriate history and/or examination	Moderate	45-59	$167.10
99205	Medically appropriate history and/or examination	High	60-74	$220.36

Conclusion

Overall, the CPT Code 99205 is one of the essential codes for medical billing, which comes under high-level medical services and allows for high reimbursement for healthcare organizations and clinics. So, it’s very important for healthcare providers to understand everything about the 99205 Code to use while billing and get accurate reimbursement for their medical services. We hope this guide helps you know everything about the 99205 CPT Code, its level, importance, guidelines, requirements, and common mistakes to avoid getting the proper reimbursement.

To know more about the 99205 CPT Code, you can get in touch with our experts at VCDoctor, a telemedicine app development company. 

FAQs

Q. When should CPT Code 99205 be used?

CPT Code 99205 should be used when a new patient visits, requiring high-level care and complex decision-making, and involves a 60-74 minute session.

Q. What level of care does CPT 99205 indicate?

99205 CPT Code represents the highest level of patient care where a doctor needs to handle complex conditions and spend time on face-to-face sessions and detailed assessments for personalized treatment plans,

Q. What documentation is needed to bill CPT Code 99205?

Billing CPT 99205 required three major things:

• Comprehensive patient history and exam
• High-complexity medical decision-making 
• Session lasting between 60-74 minutes

Q. What is the 2024 reimbursement rate for Code 99205?

In 2024, the reimbursement rate of the 99205 CPT is around $220.36.

Q. Is CPT Code 99205 applicable to established patients?

No, it is used for new patient visits and can’t be applied to established patients.

Q. How can providers ensure correct billing for 99205?

Providers should ensure accurate billing by documenting everything from session time length, patient history, and complexity of decision-making notes and then use the right CPT code while billing to get proper reimbursement.