Rectal fistula, unspecified
ICD-10 K60.40 is a billable code used to indicate a diagnosis of rectal fistula, unspecified.
K60.40 refers to an unspecified rectal fistula, a pathological connection between the rectum and surrounding tissues or organs. Clinically, patients may present with symptoms such as rectal pain, discharge, or recurrent infections. The anatomy involved typically includes the rectum, anal canal, and adjacent structures, which may be affected by inflammatory bowel disease, trauma, or surgical complications. Disease progression can lead to chronic inflammation, abscess formation, and significant morbidity if left untreated. Diagnostic considerations include a thorough patient history, physical examination, and imaging studies such as MRI or endoscopy to assess the extent of the fistula and rule out associated conditions. Accurate diagnosis is crucial for determining the appropriate management strategy, which may involve surgical intervention or conservative treatment depending on the complexity and location 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
K60.40 encompasses rectal fistulas that do not have a specified underlying cause. This includes idiopathic fistulas and those resulting from trauma or surgical complications without further classification.
K60.40 should be used when the specific type or cause of the rectal fistula is not documented. If the fistula is associated with a specific condition, such as Crohn's disease or diverticulitis, the corresponding specific code should be utilized.
Documentation should include a detailed clinical assessment, imaging studies confirming the presence of a rectal fistula, and any relevant surgical history. Clear notes on the patient's symptoms and treatment plan are also essential.
