Ob-Gyn Coding Alert

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 a 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 (99384-99387 and 99394-99397, Preventive medicine service) or procedure (such as 51701, Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]):

- Write two paragraphs--one for the well check or procedure and one for the sick visit
- Use two templates--use a standard preventive medicine service form and record the sick visit information on the back
- Combine a template with dictation--complete a well-check template and attach the sick-visit dictation.

Each entry should include the components necessary for that service or procedure. For instance, the well-check portion would document the preventive medicine service's comprehensive nature, including an age- and gender-appropriate history and exam.

The sick visit 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 dominates the service, the subject of discussion.

Creating separate documentation substantiates your modifier 25 claim. If you need to appeal for sick-visit payment, you can send the payer notes that visually show the modifier 25 service as significant and separate from the procedure or well check.

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.