Question: A CRNA performed an IV insertion on a patient who was in the GI lab. The reason given for her inserting the IV was “difficult IV in GI lab for procedure.” What would be the best diagnosis?
Answer: If “difficult IV in GI lab for procedure” is the only documentation you have, you will either choose diagnosis I87.2 (Venous insufficiency [chronic] [peripheral]) or I87.9 (Disorder of vein, unspecified). If you find other details in the documentation that can help you select a more specific diagnosis, choose that instead. The more you can emphasize to your providers that their detailed documentation helps you code more accurately, the better.
New Mexico Subscriber