99205 CPT Code: New Patient

How Can I Confidently Bill CPT Code 99205 for New Patients?

Navigating the complexities of CPT code 99205 for new patient encounters can feel like walking a tightrope. You know the patient’s condition is complex, and you’ve invested significant time and cognitive effort, but you’re hesitant to bill the highest-level E/M code for fear of audits or denials. This is a common pain point we see discussed in medical forums and on Reddit, where clinicians often ask for clarification on when and how to use 99205 appropriately. The key to confidently billing 99205 lies in a deep understanding of its requirements and meticulous documentation. This code is reserved for new patients with the most complex medical issues, requiring a high level of medical decision-making (MDM) or a substantial amount of time. Think of it as the code for those head-scratcher cases that consume your mental energy and demand a deep dive into the patient's history and potential treatment pathways. To ensure you're billing accurately and getting reimbursed for your work, it's crucial to align your documentation with the stringent criteria for this code. Explore how you can master the use of 99205 by focusing on either MDM or time, and learn to create audit-proof documentation that tells the story of a complex patient encounter.

What Are the Key Differences Between Billing 99205 Based on Time vs. MDM?

Since the 2021 E/M coding updates, you now have the flexibility to select the level of service based on either the total time spent on the encounter or the complexity of your medical decision-making. This is a significant shift from the old system, which required a more rigid approach to documentation. For CPT code 99205, this means you can either document a total of 60-74 minutes of service on the date of the encounter or demonstrate a high level of MDM. This choice allows you to select the method that best reflects the nature of the patient visit. For instance, a lengthy visit that involves extensive counseling and patient education might be best captured by time, while a visit with a very complex differential diagnosis and risk assessment might be better suited for MDM-based billing. Consider implementing a workflow where you and your billing staff can quickly identify which method is more advantageous for each 99205 encounter. This can be as simple as a checklist or a feature in your EHR that prompts you to consider both options.

How Do I Document High-Complexity Medical Decision-Making for 99205?

Documenting high-complexity MDM is the cornerstone of justifying a 99205 code when you're not billing based on time. Think of your documentation as a story that paints a clear picture of a complex patient for a third-party reviewer. To meet the criteria for high-complexity MDM, you need to demonstrate a high level of complexity in at least two of the following three areas:

• Problems Addressed: This involves a patient presenting with one or more chronic illnesses with severe exacerbation, or a new, acute illness or injury that poses a threat to life or bodily function. For example, a new patient with uncontrolled diabetes, hypertension, and early signs of kidney disease would likely meet this criterion.

• Data Reviewed and Analyzed: This includes a comprehensive review of external records, ordering and interpreting multiple tests, and/or the use of an independent historian. For instance, if you review a new patient's records from a previous specialist, order a battery of new labs and imaging, and discuss the case with another provider, you are demonstrating a high level of data analysis.

• Risk of Complications and/or Morbidity or Mortality: This element focuses on the risk associated with the patient's condition, the diagnostic procedures, and the treatment options. A decision to start a high-risk medication, such as an immunosuppressant, or to recommend a major surgical procedure would fall into this category.

To make your documentation more robust, consider using a template in your EHR that prompts you to address each of these MDM elements. You can also use tools like Grammarly to ensure your notes are clear, concise, and free of errors that could create ambiguity during an audit.

What Are Some Real-World Examples of a 99205 New Patient Encounter?

Sometimes, the best way to understand a CPT code is to see it in action. Here are a few scenarios that would likely warrant a 99205 code:

• The Complex Geriatric Patient: A new 85-year-old patient with a history of coronary artery disease, congestive heart failure, and type 2 diabetes presents with a new complaint of worsening shortness of breath and fatigue. The visit requires a thorough review of their extensive medical records, a detailed physical exam, ordering new cardiac and metabolic labs, and a lengthy discussion with the patient and their family about potential medication adjustments and the need for a cardiology referral.

• The New Cancer Diagnosis: A new patient is referred to you for a suspicious lung nodule found on a recent imaging study. The visit involves a detailed discussion of the findings, a review of the imaging with a radiologist, a comprehensive physical exam, and a lengthy conversation about the next steps, which may include a biopsy and referral to an oncologist. The emotional weight of the conversation and the complexity of the shared decision-making process contribute to the high level of service.

• The Mental Health Crisis: A new patient with a history of anxiety and depression presents with a severe exacerbation of their symptoms, including suicidal ideation. The visit requires an in-depth psychiatric evaluation, a risk assessment, coordination of care with a mental health professional, and the development of a comprehensive safety plan. The high-risk nature of the patient's condition and the complexity of the management plan justify the use of 99205.

In each of these examples, the clinician is dealing with a high-stakes situation that requires a significant investment of time, expertise, and cognitive effort. These are not your routine, straightforward new patient visits.

How Can I Avoid Common Mistakes When Billing for 99205?

Billing for 99205 can be a double-edged sword. While it offers the highest reimbursement for a new patient visit, it also carries the highest risk of scrutiny from payers. To avoid common pitfalls, it's essential to be proactive and meticulous in your billing practices. Here are some of the most common mistakes to avoid:

• Insufficient Documentation: This is the number one reason for 99205 denials. Your documentation must clearly support the level of service you are billing for. If you're billing based on time, you need to document the total time spent and a summary of the activities performed. If you're billing based on MDM, your notes must reflect the complexity of the patient's problems, the data you reviewed, and the risk involved.

• Overbilling: It can be tempting to upcode a visit to 99205 to increase reimbursement, but this can lead to audits and penalties. Be honest and accurate in your coding. If a visit doesn't meet the criteria for 99205, don't bill for it.

• Under-coding: On the other hand, many clinicians are so afraid of audits that they consistently under-code their services. This can lead to a significant loss of revenue over time. If you're providing a 99205-level service, you should be billing for it.

• Not Documenting Time Correctly: When billing based on time, you must document the total time spent on the encounter on the date of service. This includes both face-to-face and non-face-to-face time. Be sure to document a brief summary of the activities you performed during that time.

• Confusing New vs. Established Patients: CPT code 99205 is only for new patients. A new patient is defined as someone who has not received any professional services from you or another clinician of the same specialty in your group practice within the last three years.

To streamline your billing process and reduce the risk of errors, consider using an AI scribe like S10.AI. These tools can help you create more accurate and comprehensive documentation, which can in turn help you to bill more confidently and effectively. Explore how AI scribes can help you capture the full complexity of your patient encounters and ensure you're getting paid appropriately for your work.