Crohn's disease of both small and large intestine w fistula

This code signifies a chronic inflammatory bowel disease affecting both the small and large intestines, characterized by the presence of a fistula. A fistula is an abnormal connection between two epithelialized organs or between an organ and the skin, often a complication of severe Crohn's disease.

Assign this code when documentation clearly indicates Crohn's disease impacting both the small and large bowel, and a fistula is explicitly noted as a current complication. This code is appropriate for patients presenting with symptoms such as abdominal pain, diarrhea, weight loss, and signs of fistulizing disease (e.g., perianal drainage, enteroenteric communication).

• Ensure documentation specifies involvement of both the small and large intestine, not just one or the other.
• Verify the presence of an active fistula; do not use for historical or resolved fistulas without current clinical relevance.
• Consider sequencing this code as a primary diagnosis when the Crohn's disease with fistula is the primary reason for the encounter.