Rectal fistula, simple
ICD-10 K60.41 is a used to indicate a diagnosis of rectal fistula, simple.
K60.41 refers to a simple rectal fistula, which is an abnormal connection between the rectum and the skin surrounding the anus. Clinically, patients may present with symptoms such as pain, swelling, and discharge of pus or fecal matter from the external opening. The anatomy involved includes the rectum, anal canal, and perianal skin. Disease progression can vary; a simple rectal fistula may arise from conditions such as abscess formation or inflammatory bowel disease but is typically less complex than a complex fistula, which may involve multiple tracts or surrounding structures. Diagnostic considerations include a thorough physical examination, imaging studies such as MRI or ultrasound, and possibly endoscopy to assess the extent of the fistula. Accurate diagnosis is crucial for determining appropriate management, which may include surgical intervention or conservative treatment options.
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
K60.41 specifically covers simple rectal fistulas that do not involve complex tracts or surrounding structures. It is typically associated with conditions like perianal abscesses or minor inflammatory bowel disease.
K60.41 should be used when the fistula is classified as simple, without additional complications or multiple tracts, distinguishing it from K60.43 for complex rectal fistulas.
Documentation should include a detailed clinical history, physical examination findings, imaging results, and treatment plans. Evidence of the fistula's simplicity and absence of complications is critical.
