Rectal fistula, simple, recurrent

This code signifies a recurrent, uncomplicated abnormal tract connecting the rectum to another organ or the skin, typically the perianal skin. "Simple" implies a single, straight tract without branching or significant associated abscesses, while "recurrent" indicates a previous history of a rectal fistula that has reappeared.

Use this code when documentation clearly states a patient presents with a simple, recurrent rectal fistula. This is often supported by physical examination findings, imaging (e.g., MRI, fistulography), and a history of prior fistula formation and treatment. It is appropriate for cases where the fistula is not complex or associated with inflammatory bowel disease.

• Differentiate from complex or secondary fistulas, which have different code assignments.
• Ensure documentation specifies "recurrent" to justify this specific code; otherwise, a non-recurrent simple fistula code may be more appropriate.
• Always review the operative report or physician notes for details on the fistula's complexity and any underlying causes.