When you look at the doctor’s bill and feel confused by all the unfamiliar codes, you’re not alone in this situation. If you visit the doctor’s office for the first time, you will see that the code first will be CPT code 99205. This is a special code, and this code has importance because it is used to help in medical offices, insurance companies, and the most important factor is that the patient can understand easily what services were provided during the visit.
In this article, we’ll inform you about everything you want to know about CPT 99205, from what it means to when it is used and why it matters for billing. Don’t worry; there is no fancy medical jargon here.
We will provide you with the information about the codes in a simple and clear manner. After this, you will feel more confident and sure the next time you see this code on a bill.
What about CPT Code 99205?
Current procedural terminology is CPT. The American Medical Association developed a long list of codes, each indicating a specific medical service or procedure.
CPT code 99205 is used for a new patient office visit. In general terms, this is when a patient sees a doctor in the office for the very first time. But it’s not just any visit, it’s a visit that involves a lot of work.
The 99205 CPT code definition explains that this code is used when the visit requires a high level of medical decision-making and the doctor spends a significant amount of time with the patient. It is considered the most complicated new patient office visit code.
The 99205 CPT Code Description Time
How much time does this visit usually take? If we see according to the 99205 CPT code description, the average face-to-face time the provider would spend with the patient is might be 60-74 minutes, which is over an hour in some cases.
This time includes:
- Reviewing the patient’s medical history
- Doing a comprehensive physical exam
- Talking through different diagnosis possibilities
- Developing a detailed treatment plan
- Satisfy the questions of patients
If your visit takes a short time but still involves complicated decision-making, the doctor might still use code 99205 medical, depending on other factors, such as the nature of the problems being addressed.
When Is Code 99205 Used?
The 99205 medical code isn’t for quick checkups or minor issues. It’s usually used when: You are a new patient (meaning this provider or another provider hasn’t seen you in the same practice within the past three years). You have multiple or complicated health problems. The doctor needs to review a lot of records and tests. The doctor must make high-risk decisions about your treatment.
By coding example, if you have several chronic illnesses, complicated symptoms in these conditions, you will require many tests, or a serious new diagnosis, the provider will often bill code 99205.
In patients with chronic conditions like anemia due to chronic disease, proper diagnosis coding such as D63.8 ICD-10 is crucial when evaluating high-complexity visits under CPT 99205.
Why Is Billing Code 99205 Important?
You will probably ask yourself: Why do these codes matter so much? Well, every medical service has a cost. Insurance companies rely on accurate coding to decide how much to pay the provider.
Billing code 99205 signals the insurance company that this was a high complexity visit. The charges for this service are higher than for simpler visits because the provider spent much more time and effort on your care.
On the other hand, the 99205 procedure code also helps ensure that doctors are paid fairly for longer, more involved appointments. It also helps patients clearly see what services were provided and why their bill might be higher.
What Are the 99205 Requirements?
It’s not meant that every visit qualifies for this code. Some specific 99205 requirements must be met. Here’s a simple breakdown:
- New Patient: The visit for those who are taken as a new patient.
- Comprehensive History and Exam: The provider is responsible for giving you a detailed check-up and history about your medical conditions before and after every visit, as well as a whole-body examination. This history also covers your aspects, such as reviewing your previous medical problems, current symptoms, medications, and sometimes family and social history.
- High Level of Medical Decision Making: This is a big part of the 99205 CPT code. The provider has to make complex decisions about your diagnosis and treatment. This could mean:
- Much of the data will be reviewed during this time (labs, imaging, records).
- Considering multiple diagnoses.
- Managing a high-risk problem.
- Time Component (60-74 Minutes): If time is used as the deciding factor instead of complexity, the face-to-face visit needs to last 60-74 minutes.
The provider will use a different, easy code if your visit does not meet the requirements.
New patient Codes Are Different From The Code 99205?
99201, 99202, 99203, and 99205 are CPT codes. If you hear about these codes from someone. These codes are used for treatments during new patient visits, but their complications could differ. Here’s how they generally compare:
- 99201: Very simple visit (no longer used as of 2021)
- 99202: Straightforward problems (low complexity)
- 99203: Low to moderate complexity
- 99204: Moderate to high complexity
- 99205: Most complicated and time-consuming.
The doctor will use the 99205 CPT code when your health is more complicated than a typical visit, which takes a lot of time.
Examples of Visits That May Use 99205
To make this simpler, let’s look at some examples:
Example #1: A patient with complicated diabetes, hypertension, and kidney disease requires a detailed assessment and a major adjustment to medications.
Example #2: A patient is referred after a hospitalization and has complex discharge instructions, lab results, and treatment plans to review. These situations involve high risk and a lot of time and effort, which is why they qualify for code 99205 medical.
How Do Providers Document a 99205 Visit?
In this process, valid documentation is needed. If a provider uses the code 99205, they should must write down about the level of services they’re offering. This record should include different things, such as a review of the system, physical examination, and a detailed history of present illness.
But the one thing that you need to be concerned about is that if your documentation doesn’t support the code, insurance companies can ask you for additional payment or possibly deny payment.
Final Thoughts
So, now we know that medical billing is complex and confusing, but knowing the basic codes is key. It can make it easy to understand. The code 99205 indicates a detailed visit with your provider, addressing complex health concerns.
The next time you see CPT 99205, 99205 procedure code, or related terms like 99205 CPT code definition, you’ll know that this code stands for a high-level new patient office visit that requires time and advanced decision-making.
These codes are a helpful tool for your providers to help in the proper documentation of your treatment and care so that they can get paid for the work they do. When you are unsure about your bills or you need any kind of information about this, then you can go to your doctor’s office or insurance company without any hesitation.
If you have clear dealings with your providers and have proper information, this can avoid confusion, as you will feel confident about your health care bills.
