CPT Coding for New Patient Office Visit with Foot/Ankle Injury
For this 55-minute new patient office visit involving a work-related left foot and ankle injury requiring MRI, the correct CPT code is 99205 (new patient office visit, high complexity), based on the 2021 time-based coding rules where 55 minutes of total time qualifies for this highest-level code.
Code Selection Based on Time
As of January 1,2021, office visit codes 99202-99205 can be selected based solely on total time spent on the date of encounter, eliminating the need to document all three key components (history, examination, medical decision-making) 1.
For CPT 99205 (new patient), the time threshold is 60-74 minutes of total practitioner time on the date of encounter 1.
Your documented 55 minutes falls just short of the 99205 threshold, making 99204 (45-59 minutes) the appropriate time-based code 1.
However, if medical decision-making complexity is high (ordering MRI for work injury with differential diagnosis and coordination of care), you can bill 99205 based on complexity alone without relying on time 1.
Medical Decision-Making Complexity Assessment
This encounter likely qualifies as high complexity (99205) based on:
Ordering advanced imaging (MRI) counts as extensive diagnostic testing 1.
Work-related injury requires consideration of workers' compensation documentation and coordination 1.
Differential diagnosis includes fracture, ligamentous injury, tendon pathology, and osteochondral lesions—all requiring different management pathways 2, 3.
Risk of morbidity includes potential for chronic instability, delayed healing, or need for surgical intervention 4, 3.
Correct CPT Code Assignment
Bill CPT 99205 if you document either:
- High complexity medical decision-making (most appropriate for this case) 1, OR
- 60+ minutes of total time (if your 55 minutes was rounded or additional time was spent) 1.
Bill CPT 99204 if:
- Medical decision-making is only moderate complexity AND total time was truly 55 minutes 1.
Critical Documentation Requirements
For time-based coding, document total time spent on the date of encounter, including face-to-face and non-face-to-face activities (chart review, ordering tests, care coordination) 1.
For complexity-based coding, document the number and complexity of problems addressed, amount/complexity of data reviewed, and risk of complications 1.
Do not use the pre-2021 documentation guidelines requiring comprehensive history and comprehensive examination—these are obsolete for office visits 1.
Common Pitfalls to Avoid
Do not undercode to 99204 or 99213 simply because it "feels safer"—this is the most common error in residency and community practice, occurring in 72% of encounters 5.
Do not bill based on old 1995/1997 E/M guidelines that required all three key components for new patients—these rules changed in 2021 1.
Do not confuse office visit codes with initial hospital care codes (99221-99223), which apply only when the patient is admitted as an inpatient 6.
Ensure the MRI order is documented in the medical record on the date of service, as this supports the high complexity designation 1.