CPT 99205

Office Visit, New Patient, High Complexity (60-74 min)

CPT 99205 is the highest-level new patient office visit, used about 3.0 million times per year. It covers a 60 to 74 minute visit with high complexity medical decision making for a new patient. Providers charge an average of $534.53 for this visit, but Medicare pays only $236.81 for the physician fee in an office setting (2.3x markup). In a hospital setting, the physician fee drops to $160.32, but the hospital adds a separate facility fee on top.

Updated May 2026Source: CMS Physician Fee Schedule

CPT 99205 at a Glance

Average provider charge: $534.53
Medicare physician fee (office): $236.81
Medicare physician fee (hospital): $160.32 + separate facility fee
Typical markup: 2.3x over Medicare office rate

Visit duration: 60 to 74 minutes
Decision complexity: High
Patient type: New (not seen before)
Beneficiaries (2023): 2.0 million

How the Medicare Rate Is Calculated

Medicare does not set prices arbitrarily. Every procedure is valued using Relative Value Units (RVUs) across three components, then multiplied by a national conversion factor of $33.4009 (2026). Here is the exact math for a 99205 visit:

Component	What It Covers	Office (Non-Facility)	Hospital (Facility)
Work RVU	Physician time, skill, and judgment	3.50	3.50
Practice Expense RVU	Rent, staff, equipment, supplies	3.23	0.94
Malpractice RVU	Professional liability insurance	0.36	0.36
Total RVU		7.09	4.80
x $33.4009	2026 conversion factor	$236.81	$160.32

Why the hospital rate is lower but you pay more: The $160.32 facility rate only covers the physician's portion. The hospital bills a separate facility fee (typically $150 to $400) on top. Combined, visits at hospital-owned practices often cost patients more than the same visit at an independent office, even though the physician payment is lower.

Medicare Rate by State

Medicare adjusts the national rate based on your location using Geographic Practice Cost Indices (GPCIs). The same 99205 visit pays differently in each state, ranging from about $212 in Arkansas to $286 in Alaska (a 35% spread).

Medicare Rate by State (2026)

Medicare adjusts payments by location using Geographic Practice Cost Indices (GPCIs). Select your state to see the adjusted rate.

Sample State Rates (Office Setting)

State	Medicare Pays	Avg. Charge	Markup
Texas (Austin)	$241.48	$534.53	2.2x
California (Los Angeles)	$260.32	$534.53	2.1x
New York (Manhattan)	$265.59	$534.53	2.0x
Florida (Fort Lauderdale)	$245.94	$534.53	2.2x
Ohio	$221.79	$534.53	2.4x
Mississippi	$214.04	$534.53	2.5x
Arkansas	$211.96	$534.53	2.5x
Alaska	$285.52	$534.53	1.9x

Rates shown are for the non-facility (office) setting using 2026 GPCIs and the $33.4009 conversion factor. The average provider charge of $534.53 is the 2023 national average from CMS utilization data. Actual charges vary by provider.

What Insured Patients Actually Pay for a 99205 Visit

If you have health insurance, you do not pay the provider's full charge of $534.53. Your insurer has a negotiated rate with the provider, typically 120% to 200% of the Medicare rate. For a 99205 visit, that negotiated rate is usually $285 to $535. What you owe depends on your plan design:

Your Situation	What You Likely Pay	How It Works
Copay plan (deductible met or N/A)	$50 to $100	Flat copay per specialist or primary care visit
Coinsurance plan (deductible met)	$57 to $107	20% of the negotiated rate ($285 to $535)
High-deductible plan (deductible NOT met)	$285 to $535	You pay the full negotiated rate until your deductible is met
Medicare Part B	$47.36	20% of the Medicare-approved amount ($236.81)
Medicaid	$0 to $5	Minimal or no cost-sharing in most states

Key concept: the negotiated rate. Your insurer contracts with providers for a discounted rate below the sticker price. This negotiated rate is what your deductible, coinsurance, and copay are calculated against. You should never pay the full billed charge of $534.53 if you are in-network. If your Explanation of Benefits (EOB) shows the full charge applied to your balance, call your insurer.

Should You Use Insurance or Pay Cash?

If you have a high-deductible health plan (HDHP) and have not met your deductible, you are paying the full negotiated rate for every visit. For a 99205 office visit, this is typically $285 to $535 through insurance. Many providers offer a cash-pay rate of $200 to $375 for the same visit, which can be significantly cheaper.

When Cash-Pay Wins

You are unlikely to meet your deductible this year (low expected utilization)
The provider's cash rate is below the insurer's negotiated rate
You want to see an out-of-network specialist without a referral
The cash rate of $200 to $375 is well below the insured negotiated rate of $285 to $535

When Using Insurance Wins

You are close to meeting your annual deductible
You expect significant medical expenses later this year
Your copay is less than the cash-pay rate
You need the visit documented for insurance continuity of care

Important trade-off: Cash payments do not count toward your insurance deductible or out-of-pocket maximum. If you pay cash for visits early in the year and then need surgery or hospitalization later, those cash payments will not have moved you closer to your deductible threshold. Factor in your overall expected healthcare spending for the year, not just the cost of this one visit.

Common Billing Problems with 99205

Upcoding from 99204 to 99205

A 99204 visit (moderate complexity, 45 to 59 minutes) pays $177.36, while a 99205 pays $236.81. That $59.45 jump (34% increase) creates a financial incentive to code visits at the higher level. If your new patient visit lasted about 50 minutes and involved a moderate number of conditions (not a highly complex diagnostic workup), ask the billing department why it was coded as 99205 rather than 99204. You can request the visit notes, which document the time spent and the complexity of decision making.

Legitimate use in certain specialties

Some specialties routinely and appropriately bill 99205 for initial evaluations. Rheumatology, neurology, and complex gastroenterology practices often see new patients with multiple chronic conditions, unclear diagnoses, and extensive workups that genuinely require high complexity medical decision making. If you are seeing a specialist for a complicated new condition, a 99205 code is not automatically a red flag. The key question is whether the documentation supports the level of complexity billed.

Facility fee on top of the physician charge

If your doctor's office was acquired by a hospital system (increasingly common), your visit may now be billed as a hospital outpatient visit. The physician charge drops from $236.81 to $160.32, but the hospital adds a facility fee of $150 to $400, making the total higher. Check your bill for a separate "facility fee" or "outpatient hospital" line item. If this is new since your doctor joined a hospital network, this is the cause.

Time-based billing errors

Since 2021, E/M office visits can be coded based on either medical decision making or total time. If time-based, 99205 requires 60 to 74 minutes of total time (including chart review and care coordination, not just face-to-face time). If your visit was 55 minutes total, it should be coded as 99204, not 99205. Providers sometimes round up on time documentation. Your patient portal may show appointment duration that contradicts the billed code.

Related Office Visit Codes

Code	Description	Time	Medicare (Office)	Avg. Charge
99204	New patient, moderate complexity	45-59 min	$177.36	$395.78
99205	New patient, high complexity	60-74 min	$236.81	$534.53
99214	Established, moderate complexity	30-39 min	$135.61	$263.55
99215	Established, high complexity	40-54 min	$192.39	$381.33

Frequently Asked Questions

How much does CPT 99205 cost without insurance?

Without insurance, a new patient office visit billed under CPT 99205 costs $200 to $375 depending on the provider and location. The national average charge is $534.53. Many providers offer a cash-pay discount of 20 to 40%, bringing the price into the $200 to $375 range. For comparison, Medicare pays $236.81 for this visit in an office setting.

What is the difference between 99204 and 99205?

CPT 99204 is a 45 to 59 minute new patient office visit requiring moderate complexity medical decision making. CPT 99205 is a 60 to 74 minute visit requiring high complexity medical decision making. The 2026 Medicare rate for 99204 is $177.36 versus $236.81 for 99205, a 34% difference ($59.45). If your new patient visit was about 50 minutes and involved moderate complexity, it should be coded as 99204.

How much does insurance pay for a 99205 office visit?

Commercial insurance plans typically negotiate rates between 120% and 200% of Medicare, meaning they pay roughly $285 to $535 for a 99205 visit. Your out-of-pocket cost depends on your plan: with a copay plan you may pay $50 to $100, with coinsurance you pay 20% of the negotiated rate ($57 to $107), and if your deductible is not met you pay the full negotiated rate.

Is CPT 99205 always a sign of overbilling?

No. CPT 99205 is the highest-level new patient office visit, but it is legitimate for complex initial evaluations. Specialties like rheumatology, neurology, and complex gastroenterology often see new patients with multiple chronic conditions, unclear diagnoses, and extensive diagnostic workups that genuinely require high complexity medical decision making. The code is appropriate when the documentation supports 60 to 74 minutes of total time or high complexity MDM. If your visit was shorter or less complex, though, it may have been upcoded from 99204.

Need Help Lowering a Medical Bill?

CareRoute Bill Defense is a done-for-you bill reduction service. We analyze the codes on your bill, identify overcharges and coding errors, and apply negotiation and reduction strategies on your behalf. If you are dealing with a bill that seems too high, we can help.

Learn about Bill Defense