Anal fistula, simple, initial
ICD-10 K60.311 is a billable code used to indicate a diagnosis of anal fistula, simple, initial.
K60.311 refers to a simple anal fistula, which is an abnormal connection between the anal canal and the skin surrounding the anus. Clinically, patients may present with symptoms such as pain, swelling, and discharge, often exacerbated by bowel movements. The anatomy involved includes the anal sphincter and surrounding tissues, which can become inflamed or infected, leading to the formation of the fistula. Disease progression can vary; if left untreated, simple anal fistulas may develop into more complex forms, potentially involving the anal sphincter and necessitating more invasive surgical interventions. Diagnostic considerations include a thorough physical examination, possibly supplemented by imaging studies such as MRI or endoanal ultrasound to assess the fistula's extent and any associated abscesses. Accurate diagnosis is crucial for determining the appropriate treatment plan, which may involve surgical options such as fistulotomy or seton placement, depending on the complexity of the fistula.
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
K60.311 specifically covers simple anal fistulas, which are characterized by a direct connection between the anal canal and the skin without involvement of the anal sphincter. It does not cover complex fistulas, which may involve multiple tracts or significant sphincter involvement.
K60.311 should be used when the anal fistula is classified as simple, with no complications or additional complexities. If the fistula is complex or involves the anal sphincter, other codes such as K60.312 should be considered.
Documentation should include a detailed history and physical examination, noting symptoms such as pain and discharge, as well as findings from any imaging studies performed. Surgical notes should clearly outline the procedure performed and the rationale for the chosen treatment.
