Anal fistula, simple, unspecified

This code represents a simple anal fistula, which is an abnormal, narrow tunnel connecting the anal canal to the skin near the anus. It typically results from an anal gland infection and is characterized by a single, uncomplicated tract without branching or significant surrounding inflammation.

Use this code when documentation specifies a simple anal fistula without further detail regarding its specific location (e.g., high or low intersphincteric, transsphincteric). This code is appropriate when the physician's notes clearly indicate a straightforward, uncomplicated fistula.

• Avoid using this code if the documentation specifies a complex anal fistula; instead, look for codes that describe complex fistulas.
• Ensure the documentation explicitly states "simple" or implies a non-complex nature; otherwise, consider codes for unspecified anal fistulas.
• Always review operative reports or clinical notes for details on the fistula's characteristics (e.g., single tract, no branching) to support the "simple" designation.