Rectal fistula, simple, initial

This code signifies a straightforward connection between the rectum and the perianal skin or another organ, characterized by a single, uncomplicated tract. It represents the initial encounter or treatment for a newly diagnosed or presenting simple rectal fistula.

Apply this code when documentation clearly indicates a simple rectal fistula, meaning it has a single, linear tract without branching or significant surrounding inflammation. This code is appropriate for the first time a patient presents with this condition or receives treatment for it.

• Ensure documentation specifies "simple" and "initial encounter" to support this code.
• Distinguish from complex fistulas (K60.5) which involve multiple tracts, recurrent disease, or association with other conditions like Crohn's.
• Consider an external cause code if the fistula is iatrogenic (e.g., post-surgical complication).