New Patient Office Visit – 60 to 74 Minutes

CPT Code: 99205

Description: This code is reserved for comprehensive new patient visits that typically last between 60 and 74 minutes. It requires a comprehensive history, a comprehensive exam, and high complexity MDM.

Key Components:

• History: Comprehensive
• Examination: Comprehensive
• Medical Decision Making: High complexity

The extensive evaluation justifies the higher level of service. Document all aspects of the encounter—including any counseling or coordination of care—that contribute to the total time and complexity.

Documentation Tips:

• Detail every component of the patient’s history and exam.
• Clearly explain the rationale behind the high complexity decision making.
• Record the total face-to-face time if using time-based coding.

Always refer to the latest CPT and payer guidelines for proper documentation requirements.