CPT 99205: New patient, high
What this code means, what it should cost, and how to dispute an overcharge.
Fair Price Reference
What is CPT 99205?
The highest-level new-patient office visit. Reserved for extensive workup and high-complexity decision-making.
Typical setting: Doctor's office / outpatient clinic.
What CPT 99205 should cost
The Centers for Medicare & Medicaid Services (CMS) pays approximately $211 for CPT 99205 under the 2025 Physician Fee Schedule. This is what the federal government has determined is a reasonable payment for this service.
Private insurance typically pays 1.2–1.8x Medicare rates ($253–$380). Hospital chargemaster prices for CPT 99205 often range from $280 to $800 — a markup of 1.3x to 3.8x over Medicare.
Common overcharges on CPT 99205
99205 is frequently upcoded. Request documentation justifying the highest-level complexity — if the visit lasted less than 60 minutes or the MDM doesn't reach 'high', the code should be 99204.
About Office Visit billing
Evaluation & management (E&M) codes for office visits are the most frequently billed codes in medicine. They are also a leading source of upcoding — where a provider bills a higher-complexity level than the visit actually supports.
Request the office visit note. Compare the documented history, exam, and medical decision-making against the 2021 AMA E&M guidelines. If the documentation doesn't support the billed level, request a downcode.
How to dispute a CPT 99205 overcharge
- Request the itemized bill. You are entitled to a detailed line-by-line bill showing every CPT code billed. Ask in writing.
- Compare to Medicare allowable. If the charge exceeds 150% of Medicare ($317), you have grounds to dispute.
- Request documentation. For E&M codes, ask for the visit note. For procedures, ask for the operative report. The documentation must justify the code billed.
- Send a formal dispute letter. Cite the specific discrepancy between the documentation and the code. Reference Medicare rates and NCCI edits where applicable.
- Follow up in writing. Give the provider 30 days to respond. If they don't, escalate to the state attorney general and insurance commissioner.
Got CPT 99205 on your bill?
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