Rectal fistula, simple, initial
ICD-10 K60.411 is a billable code used to indicate a diagnosis of rectal fistula, simple, initial.
K60.411 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 persistent drainage of fecal matter, discomfort, and irritation in the perianal area. The anatomy involved includes the rectum, anal canal, and surrounding soft tissues. Simple rectal fistulas typically arise from conditions like abscesses or inflammatory bowel disease, and they may progress if left untreated, leading to more complex fistulas or recurrent infections. Diagnosis is primarily clinical, supported by physical examination and possibly imaging studies such as MRI or endoscopy to assess the extent of the fistula and rule out other gastrointestinal disorders. Accurate diagnosis is crucial for appropriate management and to prevent complications.
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
K60.411 specifically covers simple rectal fistulas, which may arise from abscesses, trauma, or inflammatory bowel disease. It does not include complex fistulas or those associated with malignancies.
K60.411 should be used when the rectal fistula is classified as simple and is the initial encounter. If the fistula is complex or has been previously treated, other codes should be considered.
Documentation should include a detailed history of symptoms, physical examination findings, imaging results if applicable, and treatment plans. Clear notes on the nature of the fistula and any associated conditions are essential.
