Anorectal fistula, simple, initial

This code describes a straightforward, uncomplicated abnormal tract connecting the anal canal or rectum to the perianal skin, presenting for the first time. A simple fistula typically involves a single, low tract without significant branching, abscesses, or involvement of the sphincter muscle beyond the superficial external sphincter.

Assign this code when documentation clearly indicates a newly diagnosed, uncomplicated anorectal fistula. This is appropriate for patients presenting with symptoms such as perianal discharge, pain, or swelling, and a physical examination confirms a simple fistula without prior surgical intervention for this specific condition.

• Ensure documentation specifies "simple" and "initial encounter" to support this code.
• Distinguish from complex fistulas (K60.512) which involve multiple tracts, high tracts, or significant sphincter involvement.
• Do not use for recurrent fistulas; refer to K60.52 for subsequent encounters or recurrent conditions.