How to Document and Code Procedures

Avatar Lorena Lugo -

In order to document Procedures successfully and to satisfy billing/coding requirements, procedures should be chosen from the treatment section.

Details need to be documented in the corresponding procedure within the Procedures window, AND medication administered is to be documented in Therapeutic Injections (if medication was administered).

Examples of Procedures with administered medications are: Nebulizer Treatment, Laceration Repair, I&D, Morgans Lens, Joint Aspiration, Join Injection, Nail Bed Repair, Ingrown Nail Removal.

On Progress Note:

1. Enter Diagnosis

2. Select Treatment

3. Select Procedures option

4. Search and Choose Procedure

Back on Progress Note:

5. Select Procedures

6. Choose corresponding Procedure

7. Document Details

8. Exit Screen by choosing X

9. IMPORTANT! Document administered Meds e.g. Lidocaine, Albuterol, Ipratropium in Therapeautic Injection window. 

NOTE: To learn how to enter new inventory into eCW and how to document medications administered, click this LINK

10. If multiple Nebulizer treatments are provided, increase units in Billing window by clicking on Procedure Codes orange font on Progress Note. Example: One Albuterol Treatment is billed with 3 units, if 3 treatments are administered increase J7613's units to 9 and 94640's units to 3


*Progress Note should reflect all details below when breathing treatments are administered.