2025 ICD-10-CM code K60.4
(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
Rectal fistula: An abnormal connection between the rectum and the skin near the anus.
Medical necessity for treatment of a rectal fistula is established based on the presence of symptoms causing significant discomfort or impairment of daily activities, risk of recurrent infections, and potential for complications such as sepsis.Surgical intervention may be medically necessary for complex fistulas that do not respond to conservative measures or for those at high risk of recurrence. Documentation of symptoms, attempted conservative measures (if any), and the rationale for surgical intervention are crucial for demonstrating medical necessity.
Diagnosis and treatment of rectal fistulas may involve several medical specialties, including gastroenterology, colorectal surgery, and general surgery. The clinical responsibility depends on the complexity of the case and the need for surgical intervention.A gastroenterologist may be involved in diagnosis and management of underlying inflammatory diseases that may be causing the fistula. A colorectal surgeon might be responsible for surgical repair of the fistula.
In simple words: A rectal fistula is an abnormal tunnel connecting the rectum (the end of the large intestine) to the skin near the anus. This can cause pain, swelling, pus, or bleeding. Doctors may treat it with medication or surgery.
K60.4, Rectal fistula, signifies an abnormal passage or tract connecting the rectum to the perianal skin.This fistula can result from various causes, including infections, trauma, or inflammatory bowel disease.The condition may present with symptoms like pain, swelling, discharge, or bleeding near the anus. Diagnosis typically involves physical examination and sometimes imaging studies like fistulography or MRI. Treatment options range from conservative measures like antibiotics and drainage to surgical interventions, depending on the complexity of the fistula.
Example 1: A 45-year-old male patient presents with recurrent perianal abscesses and drainage.Physical examination reveals a palpable tract consistent with a rectal fistula.Further investigations (fistulography) confirm the diagnosis.The patient undergoes surgical repair (fistulotomy) of the fistula., A 60-year-old female patient with Crohn's disease develops a complex trans-sphincteric rectal fistula. This requires advanced imaging (MRI) for precise delineation of the fistula tract and possibly a more complex surgical procedure like a seton placement or flap repair., A 30-year-old patient presents with a small, low-lying rectal fistula after a previous anal infection.Conservative management with antibiotics and careful wound care is attempted initially, with surgical intervention considered if the fistula does not heal.
Complete medical history, including details about the onset of symptoms, previous infections, inflammatory bowel disease (if applicable), any prior treatments, and any associated complications.Detailed physical examination findings, documenting the location, size, and characteristics of the fistula tract.Results of imaging studies such as fistulography or MRI, if performed.Documentation of surgical procedures performed, including the type of surgery and any complications encountered.Postoperative progress notes, including details about wound healing and any complications.Any relevant lab data (such as white blood cell count).
** The information provided here is for educational purposes and should not be considered medical advice.Always refer to the most current coding manuals and guidelines for accurate coding practices.
- Payment Status: Active
- Specialties:Colorectal Surgery, Gastroenterology, General Surgery
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center