Billing code 99205: Office visitMedicare rate & RVUs in Illinois
Highest-level new patient office or outpatient visit, reported when medical decision making is high or the billing practitioner's total time reaches 60 minutes.
Medicare pays $234.20–$253.74 for 99205 in the office in Illinois, from Rest Of Illinois to Chicago. Which amount applies depends on the service address.
Medicare allowed amount for participating (non-QP) physicians, before deductible, coinsurance and claim adjustments. Not a patient’s bill or a hospital charge.
On this page 9 sections
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.
Where 99205 pays more and less in Illinois
The same RVUs, adjusted for each area’s costs. Open a locality for its calculation, history and nearby areas.
4 payment localities
$234.20 to $253.74
| Payment locality | Office | Facility |
|---|---|---|
| Chicago | $253.74 | $176.87 |
| East St. Louis | $240.37 | $170.01 |
| Rest Of Illinois | $234.20 | $164.36 |
| Suburban Chicago | $249.83 | $171.27 |
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.
How the rate is built · 99205
RVUs × geographic indexes × conversion factor
Swap in your local Medicare rate.
Work 3.50Practice expense 3.23Malpractice 0.36
All indexes start at 1.000 (the national rate). Enter a ZIP or drag a slider.
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.
Place of service · 99205
Which rate does Medicare pay?
The POS code on the claim line (CMS-1500 box 24B).
Non-facility (office) rate · national
$236.81
The facility rate would be $160.32 (+$76.49). In a facility, the facility bills its own costs separately.
99205 compared with similar codes
Compare codes
99205 vs 99204 vs 99215 vs 99245 vs 99223: national Medicare rates
Swap in your local Medicare rate.
How to choose
- 99204Office visit
- 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 visit
- 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.
- 99245Off/op consltj new/est hi 55
- 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 visit
- 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.
99205 billing questions
How is 99205 distinguished from 99204?
99205 requires high medical decision making or at least 60 minutes of total time; 99204 requires moderate decision making or at least 45 minutes. A severe problem alone does not establish high decision making: two of the three decision-making elements must reach the high level.
What counts toward the 60 minutes?
Count the billing practitioner's qualifying work on the encounter date, such as record review, examination, counseling, ordering, documentation, and care coordination. Exclude clinical staff time and time spent on separately reported services.
How is prolonged time reported beyond 99205 for Medicare?
Medicare uses G2212 with 99205 for prolonged office or outpatient time; the first unit begins at 89 total minutes, with additional units at subsequent 15-minute thresholds. Payers following billing code prolonged-service rules may instead use 99417, with its first unit beginning at 75 minutes.
Can 99205 be billed when a Medicare patient is referred for a consultation?
Medicare does not pay office consultation codes 99242–99245. Report the appropriate office or outpatient visit code, including 99205 when the patient qualifies as new and the level is supported.
When is modifier 25 needed with 99205?
Append modifier 25 when a significant, separately identifiable E/M service is performed on the same date as a minor procedure. Document evaluation beyond the work normally included with that procedure.
Can G2211 be added to a new patient visit?
Yes, when the visit reflects the practitioner's continuing role as a focal point for care or ongoing care for a serious or complex condition. Medicare generally excludes G2211 when modifier 25 is appended, but permits it when the same-day service is an annual wellness visit, vaccine administration, or Medicare Part B preventive service.
99205 is in these specialty bundles: Primary care
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
Show the CMS file lines behind this rate
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