Incomplete defecation
ICD-10 R15.0 is a billable code used to indicate a diagnosis of incomplete defecation.
Incomplete defecation refers to the sensation of an inability to completely evacuate the bowels during a bowel movement. Patients may describe this as feeling as though they still need to pass stool after having a bowel movement. This symptom can be associated with various gastrointestinal disorders, including constipation, rectal prolapse, or anal fissures. It may also arise from functional bowel disorders such as irritable bowel syndrome (IBS) or pelvic floor dysfunction. The sensation can lead to significant discomfort and distress, impacting the patient's quality of life. Clinically, it is important to differentiate between true incomplete evacuation and other causes of altered bowel habits. A thorough history and physical examination, along with appropriate diagnostic tests, are essential to identify underlying causes and guide management. Laboratory findings may include stool studies to rule out infections or malabsorption syndromes, while imaging studies may be necessary to evaluate structural abnormalities.
Detailed patient history, including bowel habits, dietary factors, and any associated symptoms.
Patients presenting with chronic constipation or changes in bowel habits.
Consideration of comorbid conditions such as diabetes or neurological disorders that may affect bowel function.
Acute assessment of abdominal pain and bowel habits, including any acute changes.
Patients presenting with acute abdominal pain and a history of incomplete defecation.
Rapid assessment and documentation of any acute complications such as bowel obstruction.
When evaluating for structural causes of incomplete defecation.
Indication for the procedure must be clearly documented.
Gastroenterology may require additional documentation for pre-authorization.
Documentation should include a detailed history of bowel habits, associated symptoms, any previous treatments, and results from relevant diagnostic tests.
