Question How is "Impossible" Total Time determined?


Clay, NY
Best answers
I have a question about "impossible time". We are a moderate sized private group practice. The practice decided to document time for all encounters. (Yes, I've seen some of the comments about this practice.) Our providers enter a CPT level. The coders can override if there is a difference between highest code MDM vs Total Time. Some of the owners of the group will complete documentation outside of normal scheduled work hours (in the evening; often from home). Some work through their lunch time. How do auditors look at the situation where a physician documents say 60 minutes more time on the date of service then the physician was actually scheduled to be in the office for the date of service? Knowing the dedication of our physicians, I have no doubt that the time recorded really was used.
Payers do not know how many hours a physician is scheduled to be in the office and there's no way for a payer to really prove that a provider did or did not spend the amount of time that they documented in the record. In addition, a payer can only get access to the records of their own patients and not of patients covered by different payers, so they have no way of really knowing how the provider is allocating (or over-allocating) their time. In my experience working on the payer auditing side, there's only one way that a payer would be alerted to a potential problem regarding time, and that is if the provider is billing a single payer for a number of services that far exceeds the amount that an individual could possibly perform in a given time period. But even this is not 100% reliable because under 'incident to' billing, a physician may be billing for multiple providers under their own credentials.

Payer auditors generally will identify potential abusive billing by looking at outliers - in other words, by comparing claims submitted by different providers and auditing just those providers whose billing patterns deviate from what most other providers bill. For outlier providers, they will request records to validate that the services were performed, but generally speaking, if the records support the codes billed, there's little they can do, unless the records reviewing are simply showing more hours of time billed than there are hours in the day. So unless the records clearly show a pattern of abusive coding or billing, the provider's word just needs to be taken at face value.
Hi there, perhaps I'm missing something but I'm not seeing a cause for concern here. If your providers are documenting their work according to the guidelines there's nothing for an auditor to object to (assuming the auditor applies the correct guidelines, which doesn't always happen). The new guidelines are designed to let providers get credit for that work.

I've never seen a specific definition of "impossible" time, but investigators/prosecutors may bring it up when they believe typical time for total services reported in a period greatly exceeds what is feasible for that period. For example if a provider billed 20 level 5 new patient visits based on time every day, day after day.
I appreciate the answers. I've been wondering is this could create problems and posts in other sections of the forum have left me concerned. This doesn't occur daily, typically only causes a difference of one level for the patient, and the documentation is supportive.
I appreciate the answers. I've been wondering is this could create problems and posts in other sections of the forum have left me concerned. This doesn't occur daily, typically only causes a difference of one level for the patient, and the documentation is supportive.
Sounds like you - and your doctors - are keeping on top of things.
I agree with @thomas7331 and @jkyles that there does not seem to be any cause for alarm here. Impossible time to me means literally billing for more than 24 hours in a day. There's more frequently what I call "suspicious time". It doesn't mean it's not possible, just rather that it's unlikely. Like if a provider is scheduled for 6 hours of patients, every 15 minutes with an hour for lunch (20 appts for the day; 4 new and 16 established). They then document for every new patient as 45 minutes and every established patient as 30 minutes. If you do the math (4x45 + 16x30) you wind up with 11 hours, which is actually very possible. The real suspicious part here is that every new patient is 45 minutes and every established 30 minutes. I would actually find it less suspicious if those 4 new patients were documented as 46 minutes, 52 minutes, 47 minutes and 51 minutes. While the insurance company would not have access to all 20 records, your internal people (like compliance) certainly do. Time documentation that is suspicious then casts a dark shadow on everything else.
I personally do not advocate for putting time on all records. It creates an unnecessary burden for most clinicians to monitor all time for all patients as it is not contiguous. They would have to keep track of:
12 minutes in the morning reviewing records, labs & CT results
24 minutes with the patient for history, exam and medical discussion (excluding any time spent on a separately billed test)
10 minutes charting - entering orders, sending prescription, note documentation
If I had a job where part of my job was to keep track of the exact number of minutes I spent every day on every single work activity I did, I would be looking for a new job.
I encourage my physicians to document time ONLY for noticeably time consuming patients. And include in the documentation some explanation.
There are certain types of specialties where documentation for all or most patients would not be burdensome and the majority of patients are time consuming (like palliative care). But for most clinicians, most patients, they could reach a new patient 99204 in far less than 45 minutes of clinician time.
I agree with all of the other advice so far here. I would say I think this comes into play more prior to 2021 for office/outpatient. I think impossible time would be more related to time based codes where it requires face to face 1:1 interaction to report the codes and they are 15 minute units like PT/OT for example. If you had a provider scheduled in clinic for X hours and they billed X amount of units per day where they had to document start/stop times for each and all of that didn't "add up".
Some reading material for the weekend.

An article on the flaws in the "impossible day" and other benchmark-based prosecutions:

Here's a case from 2020 that includes "impossible day' allegations:

Note that the DOJ also accused the provider of billing for services on days when he was not in the U.S. A provider who claims that while vacationing in Europe they treated patients in the U.S. is a much better example of an "impossible day," in my opinion. 😁
I just recently audited a provider who had "impossible days".

He documented "40 minutes spent" on 95% of his encounters. this included 15 minute appointments AND double booked 15 minute appointments, that were each documented with "40 minutes spent".
The day was impossible because if you added up the amount of 'documented' time spent, it was more than the hours than he could reasonably spend in a day. every day.
After having a discussion with him, he has switched to using MDM to level his visits most of the time, and his documentation has improved.