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2025 ICD-10-CM code K61.0

Anal abscess; perianal abscess.

Refer to the official ICD-10-CM coding guidelines for detailed information on proper coding and sequencing practices.Pay close attention to the inclusion and exclusion notes to ensure accurate coding.

Medical necessity is established by the presence of a symptomatic anal abscess causing significant pain, fever, and potential for sepsis.Incision and drainage are necessary to alleviate symptoms, prevent further spread of infection, and facilitate healing.

Diagnosis and treatment of anal abscess, which may involve incision and drainage, antibiotic administration, and management of potential complications.

IMPORTANT:Excludes intrasphincteric abscess (K61.4)

In simple words: This code describes an infection near the anus that causes a painful, pus-filled lump.It's often called an anal or perianal abscess.

K61.0 in the ICD-10-CM classification system codes for anal abscess, also known as a perianal abscess.This refers to a localized collection of pus near the anus, typically caused by infection of the anal glands.The abscess may be located in the perianal tissues but is excluded from coding if it is intrasphincteric (K61.4).

Example 1: A 45-year-old male presents with severe anal pain, swelling, and fever.Physical examination reveals a fluctuant perianal mass.The diagnosis of anal abscess is confirmed, and incision and drainage are performed.Post-operative antibiotics are prescribed., A 28-year-old female reports a painful lump near her anus for the past week, accompanied by increasing pain and fever. Examination reveals a tender, fluctuant perianal abscess.The patient undergoes incision and drainage under local anesthesia in an outpatient setting.Wound care instructions are provided., A 60-year-old male with a history of Crohn's disease develops a perianal abscess.He presents with severe pain, fever, and malaise.Incision and drainage are performed in the hospital setting, with subsequent monitoring for complications and potential need for further treatment such as seton placement.

Complete history and physical examination noting the location, size, and character of the abscess.Documentation of the procedure performed (incision and drainage), amount of pus drained, and any complications encountered.Results of any cultures performed and antibiotic administration details should also be included.Post-operative instructions and follow-up plan.

** Accurate coding requires careful differentiation between anal abscesses and other perianal conditions such as fissures, fistulas, or intrasphincteric abscesses.The location and clinical presentation are key factors in determining the appropriate ICD-10-CM code.

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