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2025 ICD-10-CM code K62.6

Ulcer of anus and rectum.Includes solitary ulcer of anus and rectum and stercoral ulcer of anus and rectum.

Do not code this if the patient has a fissure or fistula of anus and rectum (K60.-) or ulcerative colitis (K51.-).

Medical necessity for using this code must be supported by documentation showing the presence of an ulcer in the anus and rectum, along with associated symptoms, and diagnostic measures taken to confirm the diagnosis. The documentation should clearly explain the need for intervention and the treatment plan, whether it's medical management, surgical intervention, or other procedures. The medical record should justify the treatment's necessity for addressing the ulcer and its associated symptoms.

Diagnosis and treatment of ulcers of the anus and rectum falls under gastroenterologists, colorectal surgeons, or general surgeons. Responsibilities include performing physical examination (including digital rectal exam),proctoscopy or other endoscopic procedures, ordering and interpreting laboratory or imaging tests for diagnosis confirmation, and determining the appropriate treatment strategy which could be medical (e.g medications) or surgical. Additionally, patient education about preventive measures and follow-up care are essential aspects of clinical responsibility.

In simple words: This code refers to an ulcer located in the anus or rectum. It includes conditions like solitary ulcer and stercoral ulcer.It does not include conditions such as fissures or fistulas of the anus and rectum, or ulcerative colitis.

Ulcer of anus and rectum.Includes solitary ulcer of anus and rectum and stercoral ulcer of anus and rectum. Excludes1: fissure and fistula of anus and rectum (K60.-) and ulcerative colitis (K51.-)

Example 1: A 60-year-old male presents with rectal bleeding and pain during bowel movements.Upon examination, a solitary ulcer is found in the rectum., A patient with chronic constipation develops a stercoral ulcer in the anus due to repeated trauma from hard stools., A patient undergoing radiation therapy for prostate cancer develops an ulcer in the anus as a side effect of the treatment.

Documentation should include details of the patient's presenting symptoms (pain, bleeding, bowel habits), physical examination findings (including digital rectal exam), any diagnostic procedures performed (proctoscopy, biopsy), and the location, size, and appearance of the ulcer. It's also crucial to document any associated conditions, treatments provided, and the patient’s response to treatment.

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