Eli's Rehab Report

Question: A consultant suggests that we 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-service claims.
 
Use one of three methods to demonstrate that an E/M service (99201-99215, Office or other outpatient visit for the E/M of a patient) 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:

 • Write two sections -- one for the E/M service and one for the procedure.
 • Use two templates -- use a standard follow-up visit form and record the procedure performed on its own template.
 • Combine a template with dictation -- complete a follow-up visit template and attach the procedure dictation.

Each entry should include the components necessary for that service or procedure.
 
The follow-up visit would then describe the separately identifiable problem-oriented E/M 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 helps substantiate your modifier 25 claim. If you need to appeal for established visit payment, you can send the payer the notes that visually show the modifier 25 service as significant and separate from the pre-procedure, intra-procedure and post-procedure work that is included in the procedure's reimbursement.
 
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.