2025 ICD-10-CM code K60.3
Anal fistula. This is an abnormal connection between the lower rectum and the skin around the anus.
Medical necessity for anal fistula treatment is established by the presence of symptoms such as pain, recurrent abscesses, or persistent drainage.The documentation should clearly indicate the severity and impact of the fistula on the patient's quality of life. The chosen treatment approach should be justified based on the complexity and location of the fistula and any underlying conditions.
Diagnosis and treatment of anal fistulas falls under the purview of general surgeons, colorectal surgeons, and sometimes gastroenterologists. They are responsible for confirming the diagnosis through physical examination and potentially imaging studies like fistulograms or MRI. Treatment options, which they determine based on the individual case, may range from conservative management with antibiotics and warm soaks to surgical interventions like fistulotomy or seton placement.
In simple words: An anal fistula is a small tunnel that forms near your bottom. It's usually caused by an infection and can be uncomfortable and sometimes painful.
An anal fistula is an abnormal tunnel that develops between the anal canal (the last part of the large intestine) and the skin around the anus. It typically arises after an infection in an anal gland, leading to an abscess (a collection of pus) that then forms a passage to the outside.Anal fistulas can cause discomfort, pain, and drainage of pus or stool.
Example 1: A patient presents with recurrent perianal abscesses and persistent drainage. Upon examination, an anal fistula is discovered. The surgeon performs a fistulotomy to open and drain the fistula., A patient with Crohn's disease develops an anal fistula.The surgeon recommends a seton placement to manage the fistula while addressing the underlying Crohn's disease., A patient reports pain and discharge from the perianal area. Examination reveals a simple anal fistula. The physician prescribes antibiotics and warm Sitz baths initially and advises follow-up for potential surgical intervention if symptoms persist.
Documentation for anal fistula should include: location of the fistula, presence of any associated abscesses or infections, any previous treatments, and the surgeon's findings during the examination (including digital rectal exam).If imaging studies are performed, reports of these should also be included.Surgical reports should detail the specific procedure performed.
** While K60.3 covers anal fistula generally, other codes within the K60 category may be needed to specify associated abscesses or cellulitis.Always check for the most specific code available for accurate billing.
- Payment Status: Active
- Specialties:General Surgery, Colorectal Surgery, Gastroenterology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office