Rectal fistula, complex, initial
ICD-10 K60.421 is a billable code used to indicate a diagnosis of rectal fistula, complex, initial.
K60.421 refers to a complex rectal fistula, which is an abnormal connection between the rectum and another structure, often the skin or another part of the gastrointestinal tract. Clinically, patients may present with symptoms such as persistent drainage, pain, and recurrent infections. The anatomy involved typically includes the rectum, anal canal, and surrounding tissues, which can become inflamed or infected due to underlying conditions such as Crohn's disease, diverticulitis, or previous surgical interventions. Disease progression can lead to significant morbidity, including fecal incontinence and chronic pain. Diagnostic considerations include a thorough history and physical examination, imaging studies like MRI or ultrasound, and possibly endoscopic evaluation to assess the extent and complexity of the fistula. Accurate diagnosis is crucial for determining the appropriate surgical or medical management, which may involve multidisciplinary care.
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
K60.421 covers complex rectal fistulas that may arise from inflammatory bowel disease, trauma, or surgical complications. It is characterized by multiple tracts or connections and may require advanced imaging for accurate diagnosis.
K60.421 should be used when the rectal fistula is classified as complex, which typically involves multiple tracts or significant tissue involvement, as opposed to simpler forms of fistulas that may not require extensive intervention.
Documentation should include a detailed clinical history, physical examination findings, imaging results, and any previous treatments or surgeries related to the fistula. Surgical notes and pathology reports may also be necessary.
