Rectal fistula, simple, unspecified

This code signifies a straightforward, uncomplicated abnormal connection between the rectum and another surface, typically the perianal skin, where the specific location or type of fistula is not documented. It indicates a less complex presentation of a rectal fistula without further detailed anatomical or etiological information.

Use this code when the medical record clearly states a "simple rectal fistula" or "rectal fistula, unspecified," without additional details regarding its complexity, specific tract, or associated conditions. Documentation should confirm the presence of a rectal fistula but lack the specificity to assign a more detailed code.

• Avoid using this code if the documentation specifies the fistula's complexity (e.g., high, low, transsphincteric) or its origin (e.g., Crohn's disease).
• Always review the entire medical record for more specific anatomical or etiological details that might allow for a more precise fistula code.
• Do not confuse this with anal fistula codes (K60.3, K60.4) unless the documentation explicitly states a rectal involvement.