Oncology & Hematology Coding Alert

Question: I heard that we should use two-entry documentation for encounters that involve a modifier 25 service. What does that mean?

Virginia Subscriber 
       
Answer: Two-entry documentation refers to recording separate notes for dual E/M services or procedure-E/M service claims.
    
Use one of three methods to demonstrate that a service (99201-99215, Office or other outpatient E/M visit) appended with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) is significant and separately identifiable from another same-day service or procedure (such as 90765, Intravenous infusion, for therapy, prophylaxis, or diagnosis [specify substance or drug]; initial, up to 1 hour): 

- write two paragraphs -- one for the procedure and one for the E/M
      
- use two templates -- use a standard service form and record the E/M information on the back
      
- combine a template with dictation -- complete a template and attach the E/M dictation.
 
Caution: Templates can be dangerous because they often tempt physicians to use -cloned notes- instead of documenting the specific services and results for the particular patient.
       
Each entry should include the components necessary for that service or procedure. For instance, the surgery or procedure portion would document the age- and gender-appropriate history and exam. The E/M would then describe the problem-oriented service's key components of history, examination and medical decision-making -- or when counseling and/or coordination of care dominate the service, the subject of discussion.
     
Creating separate documentation substantiates your modifier 25 claim. If you need to appeal for the patient visit payment, you can send the payer notes that visually show the modifier 25 service as significant and separate from the procedure performed.
 
Two-entry documentation also shows that the modifier 25 service -satisfies the relevant criteria for the respective E/M service- reported, which CPT's revised modifier 25 description requires.
 
Check out the OIG's report on modifier 25 use at www.oig.hhs.gov/oei/reports/oei-07-03-00470.pdf.