2025 ICD-10-CM code K61.1
Rectal abscess.
Medical necessity for K61.1 is established by the presence of a rectal abscess causing symptoms such as pain, fever, and swelling.Treatment is necessary to alleviate symptoms, prevent complications (e.g., sepsis, fistula formation), and improve the patient's quality of life.
Diagnosis and treatment of rectal abscesses fall under the purview of general surgeons, colorectal surgeons, and sometimes gastroenterologists.The physician is responsible for accurately diagnosing the abscess through physical examination and imaging studies, determining the appropriate treatment approach (e.g., incision and drainage, antibiotics), and managing any complications.
In simple words: A rectal abscess is a pocket of infection near the rectum.
Rectal abscess.A localized collection of pus in the tissues surrounding the rectum.
Example 1: A 35-year-old male presents with severe rectal pain, fever, and swelling near the anus.Physical examination reveals a fluctuant mass consistent with a rectal abscess.Incision and drainage are performed., A 50-year-old female with Crohn's disease develops a rectal abscess as a complication.She undergoes incision and drainage along with ongoing management of her Crohn's disease., A 60-year-old male with diabetes presents with a recurrent rectal abscess.After initial drainage, further investigation reveals an underlying fistula, which requires surgical intervention.
Documentation for K61.1 should include: physical examination findings (e.g., presence of swelling, tenderness, fluctuance), imaging results (if obtained), details of the incision and drainage procedure (if performed), and any associated diagnoses (e.g., Crohn's disease, diabetes).
- Specialties:General Surgery, Colorectal Surgery, Gastroenterology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office