99205 CPT Code Coding Guidelines For Coders

 CPT code 99205 is a code used to report a new patient evaluation and management (E/M) service at the highest level of complexity. The following are the coding guidelines for CPT code 99205:

1. Definition: CPT code 99205 describes a comprehensive evaluation and management service provided to a new patient, which requires a thorough history, examination, and medical decision-making of high complexity.
2. Time: The typical time required to perform and document a comprehensive new patient evaluation and management service (99205) is 60 minutes.
3. Documentation: The documentation for a comprehensive new patient evaluation and management service (99205) must include the following elements:
   • Chief complaint
   • History of present illness
   • Review of systems
   • Past medical, family, and social history
   • Physical examination
   • Medical decision-making
   • Diagnostic and/or therapeutic orders
   • Risk assessment
   • Counseling
   • Coordination of care
   • Time spent with the patient and/or family
4. Medical decision-making: Medical decision-making for a comprehensive new patient evaluation and management service (99205) must be of high complexity. It must involve the evaluation of at least two of the following three components:
   • The number and complexity of problems addressed
   • The amount and/or complexity of data reviewed and analyzed
   • The risk of complications and/or morbidity or mortality of patient management
5. Coding accuracy: The correct use of CPT code 99205 requires that the physician provides a comprehensive new patient evaluation and management service that meets the above criteria. Coders should ensure that the documentation supports the level of service billed and that all necessary components are included.
6. Reimbursement: The reimbursement for CPT code 99205 is typically higher than that for lower-level E/M services, reflecting the higher level of complexity and time required for the service. However, reimbursement may vary depending on the payer and geographic location.
7. Modifiers: Modifiers may be used with CPT code 99205 to indicate specific circumstances, such as when the service was provided in a facility setting or when a significant, separately identifiable service was provided in addition to the E/M service.

In summary, accurate coding of CPT code 99205 requires thorough documentation and medical decision-making of high complexity. Coders should ensure that all necessary components are included and that the level of service billed is supported by the documentation.