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CPT Code 99205: New Patients, Guidelines, and Requirements

Doctor consulting with a new patient, representing CPT code 99205 for high-complexity evaluation and management services.

Are you getting mixed up with the services associated with the CPT code 99205? We’re here to clear all your doubts with a detailed blog on this code. We will look at the terms of new patients, professional services, and group practices in detail.

There are some key guidelines mentioned as well with which you can seamlessly code your medical services. In the end, we discussed a lot of documentation requirements that you must fulfil while assigning this code. Contact Health Quest Billing to get your services accurately coded.

What Is CPT Code 99205?

The American Medical Association maintains the CPT code 99205. It is a medical procedural code that comes under the New Patient range. You can assign this code whenever you see a new patient in an office visit or other outpatient visits.

Those visits should involve evaluation and management services. These services are based on a high level of medical decision-making. Assigning this code also depends on providers spending 60 or more minutes on an encounter on a single date.

The purpose of assigning this code is to make diagnoses for patients. The full form of CPT in medical coding is Current Procedural Terminology. This name is associated with specific numeric codes that are assigned to medical services.

Who Is a New Patient?

The CPT guidelines indicate that a new patient must not have undergone procedures performed by a specific provider. Such procedures must not have been conducted within the last three years by the same speciality.

You should accurately differentiate your new patients from the established ones. The range of New Patient codes must be used correctly as well. These conditions must be met for complete reimbursement.

Providers must also understand key terms like ‘professional services’ and ‘group practice’. It can be difficult for primary care physicians to integrate this definition into their coding habits.

What Are Professional Services and Group Practices?

Professional services are the medical services provided by physicians or qualified healthcare providers. They are provided face-to-face in person and reported by specific CPT codes. You can use this definition to determine whether your patients are new or established.

It is based on whether you provided face-to-face services to them within the last three years. If you have not, the patient can be considered new. These services can be billed using specific codes from the New Patient code range. A group practice refers to healthcare facilities where multiple providers work together.

Some common examples of group practice are medical groups and clinics. It can get complicated to define a new patient in group practices. The patient may have seen other providers within that group. The specialty designation of a provider matters in this scenario
Suppose a patient regularly receives care from a paediatrician within a practice. After crossing the age of 18, they can transfer their care to a family physician within that practice. In this case, the practice would consider them new.

Impact of Code Range on 99205 Practice

A new CPT code range is introduced to provide details about the complexity of patient visits. It also reflects the amount of time required to complete it. This can impact your practice in several ways. You may have to adjust your documentation practices to make accurate medical decisions.

You may have to update your electronic health record templates as well. The new codes can also impact the reimbursement rates set for new patient visits. Insurance companies can adjust their rates as well based on the complexity of those visits. This could lead to both higher or lower rates for your practice.

This way, those new codes will impact patient satisfaction and retention. Patients are more likely to return to you if you thoroughly assess their medical history. They also appreciate a comprehensive treatment plan developed. You can accurately record the complexity of your visits to demonstrate your high-quality care.

Key Guidelines for Assigning CPT Code 99205

There are some key guidelines set that you must follow while assigning the CPT code 99205. Let’s take a look at them in detail:

Service Level Requirements

The CPT code 99205 applies only to new patients. They have not received professional services from the same physician. Any other physician of the same speciality is also not involved with them. In both cases, the time limit is within the past three years.

This code requires a comprehensive patient history which includes four key elements. Those elements comprise chief complaints and a history of present illness. The other two elements are ra eview of systems and past, family, and social history.

A comprehensive examination means performing a complete examination. It should cover multiple systems of a patient. You must also perform high-complexity medical decision-making. It should include an extensive evaluation and analysis of diagnostic factors.

Time-Based Coding Criteria

The code 99205 is time-based. You should only use it if the total time spent on the date of the encounter is 60 to 74 minutes. The time includes both face-to-face time and non-face-to-face activities. The entire duration must occur on the same date of service.

The time can be a key factor for billing. In this case, you must document it in the patient record. It should indicate the start and end times of each component.

Medical Necessity and Complexity

Your patients should present with complex conditions. You must also conduct extensive evaluations on them with comprehensive differential diagnoses. There can be high-risk factors associated with the conditions of your patients as well.

You should consider such factors as possible medication interactions. There is also a potential for adverse outcomes and a need for specialized therapeutic procedures.

Documentation Requirements

The medical record must include detailed notes. They can be about the patient’s history, examination findings, and the MDM process. For history, document all elements including HPI, ROS, and PFSH. For examination, ensure findings from the evaluation of multiple systems are clearly outlined.

For MDM, indicate the complexity of the patient’s condition. You can also outline any differential diagnoses and the justification for high-complexity MDM. Document why the evaluation of the patient’s condition requires that MDM.

Coding and Time-Based Restrictions

You cannot use CPT 99205 if the patient’s condition does not justify a comprehensive history. The condition also applies if you cannot justify an examination and high-complexity MDM. You may spend less than 60 minutes in total on the date of service.

In this case, you cannot assign the code 99205 even if the complexity of the MDM is high. There can be some cases where the MDM complexity is not high. In such cases, you can use a different CPT code. The code selection should be based on the complexity and time spent.

Documentation Requirements for CPT Code 99205

Healthcare providers must also fulfil certain requirements in terms of their documentation. We have listed some of those requirements below:

Specificity in Symptom Documentation

When documenting symptoms, it is crucial to use precise descriptors. They capture the exact nature of the patient’s complaint. Do not simply write “pain”. Specify the type as well. A good example is “sharp and stabbing pain in the left upper quadrant lasting for 30 minutes.”

Document the symptoms in detail. Include mentioning location, duration, severity, and timing as well. Record any aggravating or relieving factors. Also, indicate the impact on the patient’s daily activities and overall quality of life.

This level of detail supports the need for a comprehensive evaluation. It also provides a better understanding of the patient’s condition. The understanding is necessary to justify the use of high-complexity codes like 99205.

Consultation with Specialists or Referrals

A patient’s condition may require a specialist’s opinion or further evaluation. In this case, clearly state why they are needed. An example would be “Referred to cardiology for further evaluation of chest pain with no clear aetiology after initial workup.”

Any findings or recommendations received from the specialist should also be added. They can include new diagnoses, recommended treatments, and follow-up instructions. There are some collaborative decisions made with the specialist as well.

You should note discussion points like complex cases requiring multiple treatment paths. This demonstrates that the patient’s condition requires a higher level of medical decision-making. It also justifies the need for comprehensive documentation and evaluation.

Care Coordination and Communication

Care coordination involves managing patient care across different providers and services. Proper documentation should include communication with other healthcare providers. Note any discussions or correspondence with other doctors.

This includes sharing test results and requesting input on treatment plans. The relevant records can be reviewed either before or after the patient visit. Document what was reviewed and how it impacted the management plan.

Arrange additional services by coordinating home health services, physical therapy, or social work. Follow-up communication with the patient should also be documented. Indicate if you called the patient to discuss test results.

Conclusion

In this blog, we explored CPT code 99205 and the key guidelines for accurate assignment. We covered essential documentation requirements, including its use for new patients, professional services, and group practices. Additionally, we discussed how code ranges impact proper coding and billing.

To ensure compliance and maximize reimbursements, contact Health Quest Billing at (415) 508-6537 for expert coding assistance.

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Frequently Asked Questions (FAQs)

What type of diagnoses are seen in level 99205?

Diagnoses include one or more chronic illnesses with severe exacerbation. There can be progression, side effects of treatment, or an illness/injury as well.

What is the difference between code 99205 and 99204?

The code 99204 requires at least 45 minutes of face-to-face time. The code 99205 requires a minimum of 60 minutes.

What is the level of service for 99205?

The CPT code 99205 is a high-level E/M code for new patients. It requires a comprehensive history, comprehensive examination, and high-complexity MDM.

What complexity of medical decision-making does code 99205 reflect?

The code 99205 represents high-complexity medical decision-making in billing and coding.

How much does Medicare reimburse for 99214?

Medicare reimburses $126.07 for CPT code 99214.

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