Ulcerative (chronic) proctitis with fistula
ICD-10 K51.213 is a billable code used to indicate a diagnosis of ulcerative (chronic) proctitis with fistula.
K51.213 refers to ulcerative proctitis with fistula, a chronic inflammatory bowel disease affecting the rectum. Clinically, patients may present with symptoms such as rectal bleeding, diarrhea, abdominal pain, and tenesmus. The anatomy involved primarily includes the rectum, which becomes inflamed and ulcerated, leading to the formation of a fistula—an abnormal connection between the rectum and surrounding tissues. Disease progression can vary, with some patients experiencing intermittent flares of symptoms while others may have persistent issues. Diagnostic considerations include a thorough patient history, physical examination, and endoscopic evaluation, often supplemented by biopsy to confirm the diagnosis and rule out other conditions. Imaging studies may also be utilized to assess the extent of the disease and the presence of fistulas. Early diagnosis and management are crucial to prevent complications such as severe bleeding, perforation, or colorectal cancer.
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
K51.213 specifically covers ulcerative proctitis with the presence of a fistula. This includes cases where the inflammation has led to the formation of an abnormal passage connecting the rectum to adjacent structures, which can complicate the clinical picture and management.
K51.213 should be used when there is clear documentation of ulcerative proctitis accompanied by a fistula. If the condition is present without a fistula, K51.211 would be more appropriate. Accurate documentation of the clinical findings is essential for proper code selection.
Documentation should include a detailed history of symptoms, results from endoscopic examinations, biopsy findings, and any imaging studies that confirm the presence of a fistula. Clinical notes should clearly outline the diagnosis and treatment plan.
