CPT code 99205: Office visit, new patient, high complexity2026 Medicare rate & RVUs in North Carolina

In North Carolina, Medicare pays $225.24 for 99205 in the office and $153.88 when it’s performed in a hospital or facility.

Check a contract rate as a % of Medicare · 99205 nationwide

Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.

What 99205 covers

This visit is for a patient who has not received professional services from the billing practitioner or another practitioner of the same specialty and subspecialty in the same group during the past three years. Potential high-complexity presentations include a severe exacerbation of chronic disease or an acute illness threatening life or bodily function; the diagnosis alone does not establish the level. Physicians, nurse practitioners, and physician assistants provide these visits in offices and hospital outpatient clinics. The facility practice expense value applies to the professional service in a facility-based outpatient setting.

Select 99205 for high medical decision making or at least 60 minutes of the billing practitioner's time on the encounter date. High decision making requires two of three elements: high-complexity problems, extensive data analysis, and high management risk. Decisions about hospitalization or emergency major surgery and drug therapy requiring intensive toxicity monitoring can support high risk. When selecting by time, document total minutes and qualifying activities; exclude clinical staff time and separately reported services. Document a medically appropriate history and examination, but do not use their extent to select the level.

This summary was written with AI assistance from CMS physician fee schedule data and checked against the CMS billing rules shown here. Rates on this page come directly from CMS files.

How North Carolina compares for 99205

Across 109 of 109 payment localities, the office rate for 99205 runs from $215.77 in Arkansas to $296.88 in Alaska. North Carolina pays $225.24. The RVUs are the same everywhere; the geographic indexes change the dollars.

Every other payment area

99205 rates by state

Office rate range in each state. Select a state to see its payment localities.

See 99205 in every payment locality

How the 99205 rate is calculated

Each of 99205’s three RVUs is multiplied by a geographic index (GPCI) for the payment locality, added up, and multiplied by the conversion factor. Drag the indexes or enter a ZIP to see what moves the rate.

Payment rules and modifiers for 99205

99205 has no global surgery period, no multiple-procedure, bilateral or assistant-at-surgery adjustment, and no professional/technical split. What changes the payment is where the service happens: the place of service on the claim decides whether Medicare pays the office or the facility rate. Billing it with a same-day procedure? See modifier 25.

99205 compared with similar codes

Same family in North Carolina

How to choose

99204Office visitNew patient, moderate complexity

Choose 99204 for moderate medical decision making or at least 45 minutes when 99205 criteria are not met. Choose 99205 for high decision making or at least 60 minutes.

99215Office visitEstablished patient, high complexity

99215 is for an established patient; 99205 is for a patient with no professional services from the practitioner or a same-specialty, same-subspecialty group member in the past three years.

99245Office consultationHigh level, 55 minutes

99245 is for a qualifying office consultation when the payer accepts consultation codes. Medicare does not pay 99245; report 99205 for a Medicare patient only when new-patient status and the visit level are supported.

99223Initial hospital visitHigh decision making or 75 minutes

99223 is an initial hospital inpatient or observation visit. Use 99205 for a qualifying new patient encounter in an office or outpatient clinic, rather than an inpatient or observation encounter.

Codes related to 99205

Related codes aren’t interchangeable: bill the code that matches the service performed.

How 99205 has changed in North Carolina

Price 99205 for an earlier date of service

Where the North Carolina rate applies

North Carolina is a Medicare payment area, not a city. Our Census mapping connects it to 785 cities and communities in North Carolina. Some span more than one payment area; confirm with the service ZIP.

• Aberdeen
• Advance
• Ahoskie
• Alamance
• Albemarle
• Alexis
• Alliance
• Altamahaw

Browse all communities in North Carolina

Where these rates come from

FeeBase calculates base physician payments from CMS work, practice-expense and malpractice RVUs, adjusted by each locality’s geographic indexes and the conversion factor. Services without a published rate are labeled, never given a made-up amount. Amounts are Medicare allowed amounts before claim adjustments: not a patient’s bill or a commercial rate.

CMS RVU26D · effective Oct 1, 2026 through the day before Jan 1, 2027

Open CMS sourceHow we calculate rates