CPT 99205: New Patient Office Visit, High Medical Decision Making
Medicare pays $243 and commercial payers pay $293 on average nationally for this procedure.
CPT code 99205 describes an office or other outpatient visit for a new patient involving a high level of medical decision making or 60+ minutes total time spent on the encounter; typical service type is evaluation and management (E/M) and the typical site of service is an office or outpatient clinic.
For related coverage guidance, see recent payer policy updates: Cardiac Computed Tomography (CCT)/Coronary Computed Tomographic Angiography (CCTA), Cardiovascular Disease Risk Assessment, Biomarkers for Myocardial Infarction and Chronic Heart Failure.
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National Reimbursement Benchmarks
Medicare's mean rate sits at $243.4, which is modestly below BUCA's average commercial mean of $292.9, indicating that commercial contracts on average reimburse roughly $49.5 more than Medicare for CPT 99205. The two averages frame the national landscape, with BUCA representing higher commercial payment levels while Medicare remains near the lower-middle of the payer distribution.
Dispersion varies meaningfully across payers. Blue Cross Blue Shield shows a range (P75−P25) of $128.6, and UnitedHealth Group the widest interquartile spread at $169.8, signaling more variability in commercial pricing. Aetna and Cigna are tighter with ranges of $133.6 and $152.1 respectively, while BUCA's IQR is $139. - these differences highlight where negotiated commercial rates cluster versus where they diverge most.