People search for how often a 99205 can be billed expecting a number. There isn't one.

There is no rule capping how many you may report in a week, a month or a year. The limit comes from somewhere else entirely, and once you see it the question answers itself: 99205 requires a new patient, and a patient can only be new once every three years. The same person cannot generate a second 99205 inside that window, because after the first visit they are established and everything afterward falls in a different code range.

Here is what the code is, what high medical decision making requires on a first visit, how the frequency question actually works, where the line sits against 99204, what it pays, and a documentation template with two worked examples.

Key Takeaway: CPT code 99205 is the office or other outpatient visit for a new patient at a high level of medical decision making, or 60 to 74 minutes of total time on the date of the encounter [1]. There is no frequency limit on the code itself. The limit is structural: a patient is new only if no physician of the same specialty and subspecialty in the same group practice has provided a professional service in the past three years, so the same patient cannot generate a second 99205 inside that window. What the visit pays is not one number. Medicare computes the fee schedule amount as the relative value units (RVUs) for the service, multiplied by the geographic adjustment factor (GAF) for your fee schedule area, multiplied by the conversion factor (CF) [2], with a non-participating supplier paid 95 percent of the participating amount [2]. Sully.ai drafts the note with the detail that supports the level you actually delivered.

What CPT Code 99205 Is

99205 is the office or other outpatient visit for a new patient at a high level of medical decision making, or 60 to 74 minutes of total time on the date of the encounter [1].

It is the top of the new patient range. 99202 sits at straightforward decision making, 99203 at low, 99204 at moderate, 99205 at high. Above it there is no higher new patient office visit code, only prolonged services added on top.

High Medical Decision Making on a First Visit

High is reached by two of the three decision making elements, not all three.

Problems addressed reaches high with one or more chronic illnesses with severe exacerbation or progression, or with an acute or chronic illness or injury that poses a threat to life or bodily function.

Risk reaches high with examples including drug therapy requiring intensive monitoring for toxicity, a decision regarding hospitalization, and a decision regarding de-escalation of care.

Data has its own extensive bar, and here is the thing specific to this code. On a first visit, the data element is reached far more often than on a follow-up. Outside records genuinely have to be obtained, read and interpreted for the first time. Results from another practice are being seen rather than recalled. A conversation with the referring clinician is a real event rather than a formality.

That is a genuine structural difference between 99205 and its established-patient counterpart, and it is the reason a complex first visit can reach high on problems and data without the risk element doing any work at all.

The Two Routes to 99205

You need one route, not both. Either 60 to 74 minutes of total time on the date of the encounter, or a high level of medical decision making [1].

The full framework, including what two of three means across all four levels, is in the 99214 article rather than repeated here.

How Often You Can Bill a 99205

There Is No Frequency Limit on the Code

Start with what is not true. There is no rule that says a clinician may report a certain number of 99205s per week, per month or per year. No threshold exists above which the code becomes unavailable.

People look for that number because the code sits at the top of the range and feels like it should have a guardrail. It does have one. It is just not a count.

A Patient Is Only New Once Every Three Years

Here is the real constraint.

A patient is new only if they have not received a professional service from a physician of the same specialty and subspecialty, in the same group practice, within the past three years. 99205 requires a new patient. Put those together and the consequence is automatic: the same patient cannot generate a second 99205 for three years.

Not because anyone capped the code. Because after that first visit they are no longer new to you. Every subsequent visit, however complex it turns out to be, falls in the 99211 to 99215 established patient range. A patient who comes back six weeks later in genuine crisis is a 99215, not a 99205, and the fact that the second visit was harder than the first changes nothing.

The three year rule, including the two conditions people forget, is covered in full in the 99204 article.

Why a Specialty Practice Looks Different, and Why That Is Fine

This is the part worth saying out loud, because the anxiety behind the frequency question is usually about proportion rather than count.

A referral-based specialty practice sees new patients almost exclusively. That is what a referral practice is. A primary care panel sees established patients almost exclusively, because the whole point of a panel is continuity.

Those two practices should not have similar new patient code proportions, and it would be strange if they did. A high share of 99202 to 99205 in a referral practice is structurally normal. A low share in primary care is equally normal. Comparing the two tells you what kind of practice you are looking at and nothing else.

So the proportion was never the question worth asking. The documentation is.

The Number Actually Worth Checking

If you want a number, here is a useful one, and a practice already has both halves of it.

Compare the count of 99205s billed against the count of genuinely new patients seen in the same period. The first cannot exceed the second.

If it does, the problem is in the new patient determination, not in coding judgment. Someone is being classified as new who was seen by a same-specialty colleague inside three years, and that is a lookup problem with a clean fix that happens before the visit.

If it does not, the 99205 count is already bounded by something real, and the only remaining question is the one that was always the actual question: does each note carry high decision making, or the time?

99204 or 99205

Source [1]. Both require a new patient, so the three year rule is settled before this question arises. The detail on 99204 is in its own article.

What moves a first visit from moderate to high is severity and the kind of decision, not how much history you took. Every new patient visit involves a full history, so history cannot be the thing that separates them. A chronic illness in severe exacerbation rather than a stable one. A decision about hospitalization rather than starting a medication.

The trap specific to new patients. A first visit always feels substantial, because everything is being established at once: the history, the medication list, the social context, the records. That feeling is real and it is not the criterion. A thorough, lengthy, genuinely conscientious first visit for three stable chronic conditions is a 99204 on decision making, and the thoroughness does not change that.

What 99205 Actually Pays

There is no single national figure.

Under 42 CFR 414.20, the fee schedule amount for a participating supplier is computed as the RVUs for the service, multiplied by the GAF for the fee schedule area, multiplied by the CF [2]. Two of those three move: the geographic adjustment factor differs in every fee schedule area, and the conversion factor is set annually and revised most years.

RVUs are established separately for physician work, practice expense and malpractice insurance [3], and the practice expense component is lower in a facility than in an office. A non-participating supplier is paid 95 percent of the participating amount [2].

Get your own figure from the CMS Physician Fee Schedule Look-Up Tool [4]: the year, the code, your Medicare Administrative Contractor (MAC) locality, and facility or non-facility. Commercial payers set their own rates separately.

If you are asking what the visit is worth to you as an employed physician rather than to the practice, the work RVU is a different number answering a different question, and it is covered in the 99204 article.

Past 74 Minutes

Above 74 minutes, prolonged services add-on coding applies, and Medicare's first threshold for it does not begin immediately where the visit band ends [1].

The mechanics of that, including the gap between the two thresholds and the fact that Medicare and CPT do not use the same add-on code, are covered in the 99215 article rather than repeated here.

The practical instruction for this article is one line. If a first visit runs past 74 minutes, record the actual total time and check which add-on code and which threshold your payer uses, rather than assuming a plain 99205 is the end of it.

Why a 99205 Comes Back

The patient was not new. Someone of your specialty and subspecialty, in your group practice, provided a professional service inside three years. This is the first thing checked and the easiest to verify, because the payer checks it against its own claims history rather than against your note.

The note reaches moderate, not high. The commonest version of this is a long, thorough, carefully written history mistaken for high complexity. Length and care are not the elements. Severity and the kind of decision are.

Time was recorded without being qualified. A figure that does not say it is total time on the date of the encounter, counting only the reporting clinician, does not support the time route. The number alone gives a reviewer no way to tell what it measures.

The diagnosis does not support medical necessity. The visit can be documented perfectly and still be denied if the submitted diagnosis does not justify a new patient visit at the top of the range.

The 99205 Documentation Template

One block, complete as written. Paste it straight into a chart, or start from the progress note template and add the new patient lines.

OFFICE VISIT, NEW PATIENT, HIGH COMPLEXITY

• Patient, date of service: (and the rendering clinician)

• New patient confirmation: (no professional service from a same-specialty clinician in this group within three years, with the date checked)

• Referral source: (who sent them, and the clinical question being asked)

• Chief complaint: "(in the patient's words)"

• History: (the full history, since none of it is on file yet)

• Outside records obtained and reviewed: (what was requested, what arrived, what you read, and what you interpreted independently; this is where the data element is usually made on a first visit)

• Examination: (findings relevant to the problems addressed, with values)

• Problems addressed today, with severity: (each problem named, and its status stated as stable, progressing, or in severe exacerbation; severity is what sets the element)

• Risk of management selected: (the decision made, and what makes it high risk; name it, for example a decision regarding hospitalization)

• Route used: (time, or medical decision making; state which)

• If time: (total time on the date of the encounter, stated in those words, counting only this clinician, and what it comprised)

• Prolonged services check: (if total time is past 74 minutes, confirm the add-on code and threshold this payer uses)

• Assessment and plan, per problem: (each problem gets its own assessment and plan, and the plan has to match the severity the assessment claims)

• Signature, credentials, date: (the clinician who performed the service)

Three lines carry this code. "New patient confirmation"decides whether 99205 is even available. "Outside records obtained and reviewed" is where a first visit usually makes the data element, and it is the line most templates leave as a single word. "Problems addressed today, with severity" carries the decision making case, because a diagnosis list without severity does not state the element.

Where Sully.ai Fits in a Complex First Visit

A 99205 is the heaviest documentation event in outpatient medicine. A full history taken for the first time, outside records read for the first time, and a high-complexity decision, all in one sitting, all of it then written up after the patient has left.

What gets lost is exactly what evidences the level. Which records you actually read rather than merely received. The severity you observed and acted on. The decision you weighed and rejected. All three were spoken aloud in the room.

Sully.ai's AI scribe drafts the note from the visit, so the problems addressed and their stated severity, the records reviewed and the risk are on the page rather than reconstructed later. It runs on a single integration across Epic, Cerner, Meditech and Athenahealth.

Two boundaries, and both are refusals.

Nothing should choose the code. Code selection is your attestation, it is what a reviewer examines, and it carries liability belonging to the person who saw the patient.

No documentation tool adds to your clock. Only the reporting clinician's own time counts toward the time route [1]. A scribe of any kind does not help a first visit reach 60 minutes.

Sully operates across 5,000+ providers, has delivered 50M+ hours of work, and prices each role 80 to 90 percent below the human equivalent [5].

Two Worked Examples

A First Visit That Is Clearly 99205

New patient, urgent referral from a nurse practitioner at an urgent care. No prior service from anyone in this group. 68 minutes total time on the date of the encounter.

New patient confirmation: No professional service from any internal medicine clinician in this group. Chart search returns no prior encounters.

Referral source: Urgent care, same day, for newly identified severe hyperglycemia with ketones on urinalysis, asked to assess urgently and decide on admission.

Chief complaint: "They told me my sugar was dangerous and sent me straight here."

History: 49 year old woman, no established primary care. Type 2 diabetes diagnosed 2021 at another practice, lost to follow-up since early 2024. Has been taking metformin inconsistently from an old prescription, none for the past three weeks. Five days of polyuria, polydipsia and 9 pounds of unintentional weight loss. Fatigue, but no vomiting and no abdominal pain. Mentally clear throughout. Lives alone, daughter nearby and available.

Outside records obtained and reviewed: Records requested from the previous practice during the visit and received. HbA1c 9.8 percent in late 2023, last documented value. Urgent care record from this morning read in full, including point of care glucose 418 mg/dL and urinalysis with moderate ketones and no nitrites.

Examination: Temperature 98.4 F. Blood pressure 118/74 lying, 104/66 standing. Heart rate 104 regular. Respiratory rate 16, no Kussmaul breathing. Mucous membranes dry. Abdomen soft, non-tender. Mental state clear and fully oriented.

Problems addressed today, with severity:Type 2 diabetes in severe exacerbation, with severe hyperglycemia, ketonuria, volume depletion and 9 pounds of weight loss over 5 days. Hypovolemia secondary to osmotic diuresis.

Data reviewed: Urgent care record and urinalysis, personally reviewed. Previous practice records obtained and read. Venous blood gas drawn today and personally interpreted: pH 7.36, bicarbonate 21, so not in ketoacidosis. Basic metabolic panel today, glucose 392 mg/dL, potassium 3.9, creatinine 1.1. Repeat HbA1c sent.

Risk of management selected:Decision regarding hospitalization. Admission actively considered given the degree of hyperglycemia, ketonuria and orthostatic change. Decided against admission on the basis of a normal venous pH, intact mental state, ability to tolerate oral fluids demonstrated in the office, and a daughter available to stay overnight. Insulin started, which requires close monitoring for hypoglycemia.

Route used: Medical decision making. Time also documented.

If time: Total time on the date of the encounter, counting only this clinician: 68 minutes, comprising review of the urgent care record before the visit, the encounter, requesting and reading the outside records, ordering and personally interpreting the blood gas and metabolic panel, the admission discussion with the patient and her daughter, and documentation.

Assessment and plan: Type 2 diabetes in severe exacerbation with ketonuria, not in ketoacidosis. Oral rehydration in the office, tolerated. Starting basal insulin 10 units at night with written sliding scale instruction and glucose monitoring four times daily. Metformin restarted at 500mg twice daily with food. Daughter present for teaching on hypoglycemia recognition and when to call. Review in person in 48 hours. Clear written instruction to present to the emergency department for vomiting, abdominal pain, breathlessness or confusion.

Why this is a 99205. Problems addressed reaches high: a chronic illness in severe exacerbation. Risk reaches high: a decision regarding hospitalization, plus insulin initiation requiring close monitoring. Data is also extensive, with outside records obtained and a blood gas independently interpreted. That is three elements at high where two were needed.

The visit also clears 60 minutes, so both routes support the code. The note states which one it used.

A Long First Visit That Is Still a 99204

New patient establishing care after relocating. 71 minutes total time.

New patient confirmation: No professional service from any family medicine clinician in this group within three years.

Referral source: Self referred, establishing care after moving from out of state.

Chief complaint: "I just moved here and I need someone to take over all of this."

History: 63 year old man with hypertension since 2012, type 2 diabetes since 2017, hyperlipidemia, and mild osteoarthritis of both knees. All four stable for at least two years. On amlodipine, metformin, atorvastatin and as-needed acetaminophen. No admissions. No chest pain, no breathlessness, no hypoglycemia, no new symptoms of any kind. Full social, family and surgical history taken.

Outside records obtained and reviewed: Records from the previous practice requested and received during the visit. HbA1c 6.9 percent four months ago. Lipid panel at target. Blood pressure log from the previous clinician averaging 128/78. Colonoscopy 2024, normal, repeat due 2034.

Examination: Blood pressure 130/80, repeated 128/78. Heart rate 72 regular. Body mass index 29. Feet examined with monofilament, sensation intact, no ulceration. Knees with mild crepitus, full range of movement.

Problems addressed today, with severity:Essential hypertension, stableand at target. Type 2 diabetes, stable. Hyperlipidemia, stableand at target. Osteoarthritis of both knees, stable.

Data reviewed: Outside records as above, read in full. No new tests ordered today.

Risk of management selected: Continuing three medications unchanged. Amlodipine dose reduced from 10mg to 5mg given consistent readings below target and occasional ankle swelling. Moderate risk: prescription drug management. No high-risk decision. No decision regarding hospitalization. No therapy requiring intensive monitoring.

Route used: Medical decision making.

If time: Total time on the date of the encounter, counting only this clinician: 71 minutes, comprising requesting and reading the outside records, the encounter, and documentation.

Assessment and plan: Four stable chronic conditions, all at target, transferring care. Amlodipine reduced to 5mg daily, blood pressure log to continue, review in 4 weeks to confirm. Metformin and atorvastatin unchanged. HbA1c and lipids due in 2 months, ordered for then. Colonoscopy not due until 2034. Vaccinations reconciled and influenza vaccine given today. Annual wellness visit scheduled separately.

Why this is a 99204 and not a 99205, and where the genuine fork is.

Look at the time first, because this is where the example gets interesting. 71 minutes sits squarely inside the 99205 band of 60 to 74 minutes [1]. The time route would support 99205, and it is recorded and qualified properly, so that route is genuinely available.

Decision making is a different answer. Four chronic conditions, all stable, none in exacerbation and none threatening life or bodily function, puts problems at moderate rather than high. One dose reduction is prescription drug management, which is moderate risk. The outside records are substantial but the other two elements do not reach high, so decision making lands at moderate. On that route this is a 99204.

So the note has to pick one and say so, which is exactly why the "Route used" line exists. Choosing the decision making route makes it a 99204. Choosing the time route makes it a 99205, and the entire defense of that code is then the 71 minute figure and what it comprised, with nothing in the clinical content supporting the level.

The honest observation: the visit was conscientious, thorough and genuinely long, and none of that is the same thing as high complexity. A first visit always feels substantial because everything is being established at once. That feeling is not the criterion, and a practice that routinely resolves this fork toward the time route on stable-patient transfers is relying on a single number in every one of those notes.

FAQ

What is CPT code 99205?

The office or other outpatient visit for a new patient at a high level of medical decision making, or 60 to 74 minutes of total time on the date of the encounter [1].

How often can 99205 be billed?

There is no frequency limit on the code itself. The limit is structural. 99205 requires a new patient, and a patient is new only if no clinician of the same specialty and subspecialty in the same group practice has provided a professional service in the past three years. The same patient therefore cannot generate a second 99205 inside that window, because after the first visit they are established and every subsequent visit falls in the 99211 to 99215 range. A practice's 99205 volume is bounded by its genuinely new patient volume, not by a rule about the code.

What constitutes a 99205?

A new patient, plus either a high level of medical decision making or 60 to 74 minutes of total time on the date of the encounter [1]. High decision making means two of the three elements at high: problems addressed, data reviewed, and risk of management.

What is the difference between CPT code 99204 and 99205?

The level of medical decision making, or the time. 99204 is moderate, or 45 to 59 minutes. 99205 is high, or 60 to 74 [1]. Both require a new patient, so the three year rule applies the same way to each.

What is the difference between CPT code 99202 and 99204?

Two levels. 99202 is straightforward decision making, or 15 to 29 minutes of total time. 99204 is moderate, or 45 to 59 [1]. 99203 sits between them at low, or 30 to 44 minutes. The evaluation and management framework these codes sit in is published by the AMA [6].

Sources

[1] Centers for Medicare & Medicaid Services — Evaluation and Management Services, MLN006764, May 2026. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf

[2] U.S. Government Publishing Office — 42 CFR 414.20, Formula for computing fee schedule amounts. https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol3/xml/CFR-2023-title42-vol3-sec414-20.xml

[3] U.S. Government Publishing Office — 42 CFR 414.22, Relative value units (RVUs). https://www.govinfo.gov/content/pkg/CFR-2023-title42-vol3/xml/CFR-2023-title42-vol3-sec414-22.xml

[4] Centers for Medicare & Medicaid Services — Physician Fee Schedule Look-Up Tool. https://www.cms.gov/medicare/physician-fee-schedule/search

[5] Sully.ai — AI Medical Scribe. https://www.sully.ai/medical-scribe

[6] American Medical Association — CPT Evaluation and Management. https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management