2025 ICD-10-CM code K61
(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
Abscess of the anal and rectal regions.
Medical necessity for coding K61 is established by the presence of an anal or rectal abscess, requiring medical or surgical intervention to relieve symptoms, prevent complications, and promote healing. This includes documentation supporting the diagnosis and the need for treatment.
Diagnosis and treatment of anal and rectal abscesses, which may involve surgical drainage, antibiotic therapy, and pain management.
In simple words: This code describes an infection that causes a pocket of pus to form near the anus or rectum.The infection causes swelling and pain.
K61, Abscess of anal and rectal regions, encompasses an infection resulting in a pus-filled cavity in the anal or rectal area.This may include conditions such as perianal abscess, ischiorectal abscess, and rectal abscess.The abscess is characterized by localized inflammation and accumulation of purulent material.
Example 1: A 45-year-old male presents with severe perianal pain, swelling, and fever.Physical examination reveals a fluctuant perianal mass. Diagnosis: Perianal abscess (K61)., A 60-year-old female reports rectal pain, tenesmus, and fever. Examination reveals a tender, fluctuant mass in the ischiorectal fossa. Diagnosis: Ischiorectal abscess (K61)., A 28-year-old male presents with severe rectal pain and purulent rectal discharge. Examination demonstrates a tender rectal mass. Diagnosis: Rectal abscess (K61).
Complete patient history including symptoms (pain, swelling, fever, discharge), physical examination findings (location, size, fluctuation of abscess), laboratory results (complete blood count, cultures), and imaging studies (if performed) are required.For surgical drainage, operative notes should be documented.
** Coding accuracy requires careful consideration of the abscess location and associated complications.Appropriate documentation is essential for accurate reimbursement.
- Payment Status: Active
- Specialties:General surgery, colorectal surgery, gastroenterology
- Place of Service:Office, Hospital (Inpatient and Outpatient), Ambulatory Surgical Center, Emergency Room