2025 ICD-10-CM code K61.39
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Diseases of the digestive system - Other diseases of intestines Diseases of the digestive system Feed
Other ischiorectal abscess; abscess of the ischiorectal fossa.
Modifiers may be applicable depending on the circumstances of the procedure (e.g., the type of anesthesia used, the location of the service), and additional procedures that may be performed.
Medical necessity for surgical intervention is established by the presence of a symptomatic ischiorectal abscess. Symptoms may include pain, swelling, redness, fever, and purulent drainage.If the abscess is causing significant discomfort or poses a risk of sepsis, medical necessity is typically accepted.
Surgical management of the abscess, possibly including incision and drainage or other surgical procedures depending on the severity and location of the abscess.Post-operative care and monitoring for complications also fall under clinical responsibility.
In simple words: This code is for an abscess (a pus-filled pocket) in the ischiorectal fossa (a region near the anus and rectum). It also includes infections in the same area.
This ICD-10-CM code classifies other specified ischiorectal abscesses.It includes abscesses of the anal and rectal regions and cellulitis of the anal and rectal regions.The code excludes abscesses specifically defined elsewhere.
Example 1: A patient presents with pain, swelling, and redness in the area near the anus.Physical examination reveals a fluctuant mass consistent with an ischiorectal abscess.The physician performs an incision and drainage procedure under local anesthesia., A patient with a history of Crohn's disease develops an ischiorectal abscess as a complication of their disease.The abscess requires a more extensive surgical procedure, possibly involving a drainage seton., A patient reports symptoms of an ischiorectal abscess, but imaging studies reveal an associated fistula. This would necessitate a different surgical approach and would require additional coding.
A complete medical history, physical examination findings documenting the location, size and characteristics of the abscess, details of the procedure performed (incision and drainage, or other surgical procedure), any pathology reports, and post-operative care notes are all required for accurate coding.If a fistula is present, documentation of that should also be included.
** Accurate coding requires a precise description of the abscess location and any associated conditions (e.g., fistula).Consult with a qualified coding specialist for any complex cases or uncertainties.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier is not usually applicable to this type of code, as the physician's work is primarily the surgical procedure itself.
- Specialties:General Surgery, Colorectal Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center