Anal fistula, simple
ICD-10 K60.31 is a used to indicate a diagnosis of anal fistula, simple.
An anal fistula is an abnormal connection between the anal canal and the skin surrounding the anus. A simple anal fistula typically arises from a previous anal abscess and is characterized by a single tract that connects the anal canal to the perianal skin. Clinically, patients may present with symptoms such as pain, swelling, and discharge from the anal region, which can be intermittent or continuous. The anatomy involved includes the anal sphincter complex and surrounding soft tissues. Disease progression may lead to recurrent infections or abscess formation if left untreated. Diagnostic considerations include a thorough history and physical examination, often supplemented by imaging studies such as MRI or endoanal ultrasound to assess the fistula's complexity and its relationship to the anal sphincter. Accurate diagnosis is crucial for determining the appropriate surgical intervention, which may include fistulotomy or seton placement, depending on the fistula's characteristics and the patient's overall health.
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
K60.31 specifically covers simple anal fistulas, which are characterized by a single tract connecting the anal canal to the skin. It does not include complex fistulas, which may involve multiple tracts or significant involvement of the anal sphincter.
K60.31 should be used when the anal fistula is classified as simple, without any complicating factors such as multiple tracts or significant sphincter involvement, which would necessitate the use of K60.32.
Documentation should include a detailed clinical history, physical examination findings, and any imaging studies performed. Notes should clearly describe the fistula's characteristics and the absence of complicating factors.
