2025 ICD-10-CM code K51.313
Ulcerative (chronic) rectosigmoiditis with fistula.
Medical necessity for the use of K51.313 is established by the confirmed diagnosis of ulcerative colitis limited to the rectosigmoid region with associated fistula formation. The documentation must clearly indicate the patient's symptoms, clinical findings, and diagnostic test results supporting both diagnoses.
Clinicians diagnosing and managing ulcerative colitis, including gastroenterologists, colorectal surgeons, and primary care physicians, are responsible for accurately documenting the diagnosis and associated complications, such as the presence of fistulas, to support the use of this code. The documentation should clearly specify the location and nature of the fistula. They are also responsible for appropriate treatment and management of the disease and related complications.
In simple words: This code indicates a patient has long-term inflammation and sores in the area where the rectum and lower part of the colon connect.It also signifies the presence of an abnormal opening or tunnel, called a fistula, in this area, which may connect to another organ or the skin.
Chronic inflammation and ulceration of the rectosigmoid colon, the area where the rectum and sigmoid colon join, accompanied by the presence of one or more fistulas. A fistula is an abnormal connection or passageway that forms between two organs or between an organ and the skin.
Example 1: A patient with a history of ulcerative colitis presents with abdominal pain, fever, and drainage near the anus. Imaging reveals a fistula extending from the rectosigmoid colon to the perianal skin. The diagnosis of ulcerative (chronic) rectosigmoiditis with fistula (K51.313) is confirmed., A patient undergoes a colonoscopy that shows inflammation and ulcers in the rectosigmoid colon. Further examination reveals an abnormal connection between the rectosigmoid colon and the bladder, consistent with a fistula. The appropriate code is K51.313., A patient with known ulcerative colitis reports persistent rectal bleeding and pelvic discomfort. Imaging studies show evidence of a rectovaginal fistula, confirming the diagnosis of ulcerative (chronic) rectosigmoiditis with fistula.
Documentation should include details regarding the location and extent of the ulcerative colitis affecting the rectosigmoid colon and the presence and characteristics of the fistula, including its location and any associated complications such as abscess or obstruction. Supporting diagnostic test results (e.g., colonoscopy, imaging studies) should also be included.
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- Specialties:Gastroenterology, Colorectal Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office