Telehealth evaluation and management claims are billed under the same two-track coding system as in-person visits: a practitioner selects the code level using either medical decision-making or total time spent on the date of the encounter. Telehealth visits often carry thinner physical-exam documentation than an in-person chart, so practitioners lean on the time pathway more heavily, and that reliance is exactly what Medicare Administrative Contractors, Unified Program Integrity Contractors (UPICs), and federal prosecutors now test. Reviewers compare the start and end times logged for a claim against every other claim billed by the same practitioner on the same date of service, looking for encounters that overlap or, aggregated across a full day, exceed 24 hours of documented care. A pattern of overlapping or improbable time entries can turn a single flagged claim into a recoupment demand across the audit lookback period, or into a referral for a False Claims Act investigation.
Two Paths to an E/M Level: Time or Medical Decision-Making
CPT gives practitioners two ways to support an evaluation and management code level: medical decision-making, based on the complexity of the problem addressed, the data reviewed, and the risk of the management plan, or total time personally spent by the billing practitioner on the date of the encounter. Total time can include chart review, ordering tests, and documentation performed that same day, not only the minutes on camera, as long as the record ties each activity to that date of service. CMS's own Evaluation and Management Services Guide permits prolonged-service billing only once total time exceeds the threshold for the highest code in the family by 15 or more minutes. Because telehealth exam findings are often limited, many practices default to time-based coding for every visit. That default is not improper by itself, but it means the practitioner's own documentation, not a physical exam, is what stands between the claim and a denial.
Documenting Total Time for a Telehealth Encounter
An E/M code billed by time has to show its math. Reviewers expect a start time, an end time, and either a stated total or numbers that add up to one, along with a description of what filled that time: history, counseling, care coordination, or record review. A note stating only that a given number of minutes was spent, without a start and end time to check it against, is treated as an unsupported time claim even when the visit clearly happened. For telehealth specifically, auditors also expect the record to confirm the patient's location and the practitioner's location at the time of the encounter, because both bear on whether the visit was billable as telehealth in the first place.
Overlapping Encounters and the Impossible-Day Analysis
Once a practitioner's claims carry documented start and end times, program integrity contractors run a simple test: do any two encounters on the same date of service overlap. A 2:00 to 2:45 p.m. visit and a 2:30 to 3:15 p.m. visit billed to the same practitioner cannot both be accurate, and a pattern of overlaps across many dates reads as a scheduling or documentation system that generates times rather than records them. Contractors and defense attorneys extend the same logic further with what the defense bar has described as an impossible-day analysis: aggregating the CPT typical time associated with every code a practitioner billed on a given date, then testing whether the total fits inside 24 hours. A day that totals well beyond 24 hours of documented time does not by itself prove fraud, but it draws exactly the scrutiny an audit or investigation is built to apply. The same contractors that request prescribing volume for a controlled-substance review, covered in When Auditors Pull Telehealth Prescribing Records, pull the appointment log and encounter notes for the identical purpose, matching what was billed to what the schedule shows was clinically possible.
A single overlapping time entry can flag one claim. A pattern of overlapping or improbable time entries across a lookback period can turn that claim into a full-scope audit.
Why Early Legal Counsel Is Critical
It is critical that telehealth providers promptly retain experienced healthcare defense counsel upon receiving an audit notice, an additional documentation request, or a subpoena involving time-based E/M billing. Early legal intervention can protect the provider's rights, shape the documentation record before a sample of flagged claims hardens into an extrapolated recoupment demand, avoid inadvertent admissions during the records exchange, and allow counsel to communicate with the contractor or investigator on the provider's behalf. Delaying representation narrows the window to correct a documentation gap before it is read as something else.
How Health Law Alliance Can Help
Health Law Alliance has handled 5,000+ matters across healthcare regulatory and audit defense over 25+ years, including telehealth E/M billing reviews built on time and overlapping-encounter findings. If your practice has received a records request or audit notice tied to time-based telehealth coding, contact Health Law Alliance's telehealth law and telemedicine attorneys for a free, confidential consultation before the response window runs.
