Primary Care Coding Alert

Hint:  Use separate code when you clinician diagnoses anal and rectal abscesses.

When your family physician diagnoses an abscess in the anorectal area, you’ll need to delve deeper into documentation to check the location of the abscess to report it accurately using ICD-10 codes.

When your family physician arrives at a diagnosis of an abscess in the anal and/or rectal area, you will have to report it with 566 (Abscess of anal and rectal regions) when using ICD-9 codes. Remember that the same code is used, regardless of the location.

 Select From 5 Codes Depending on Abscess Type

When you begin using ICD-10 codes, 566 in ICD-9 will crosswalk to the K61 (Abscess of anal and rectal regions) family of codes in ICD-10. Be aware that K61 further expands into five more codes that are based on the location of the abscess in the anal and/or rectal area:

• K61.0 – Anal abscess –This includes perianal abscess, but don’t code abscess of the anal sphincter using this code (see K61.4 below).
• K 61.1 –Rectal abscess – This includes perirectal abscess, but don’t code abscess of the ischiorectal fossa using this code (see K61.3 below).
• K61.2 –Anorectal abscess
• K61.3 –Ischiorectal abscess
• K61.4 –Intrasphincteric abscess

Focus on Symptoms and Diagnostic Details in Documentation

Your family physician will arrive at a diagnosis of anorectal abscess based on findings of history, signs and symptoms, examination, observational findings, imaging studies, and laboratory findings. In certain cases, he might resort to other laboratory tests, such as blood tests or a urinalysis. Your clinician might also want imaging studies such as an MRI, CT scan, or an ultrasound, especially when the abscess is in the deeper areas of the rectum, to arrive at a diagnosis of a rectal abscess.

Some of the symptoms that you are more likely to see in a patient suffering from an anorectal abscess will include pain in the anorectal area, fever (R50.9, Fever, unspecified), pus discharge, swelling in the anorectal area that could possibly be felt like a lump, pain in the lower abdominal area (R10.30, Lower abdominal pain, unspecified), constipation, and pain during bowel movements.

Example: Your physician assesses a patient suffering from severe anal pain with pus discharge. He complains of lower abdominal discomfort and severe pain during bowel movements. Upon examination, your family physician notes a sizeable lump in the anal area with discharge of pus. He orders a blood test and urinalysis to confirm a diagnosis of abscess in the anal region. You report the evaluation the patient with 99203 (Office or other outpatient visit for the evaluation and management of a new patient…Typically, 30 minutes are spent face-to-face with the patient and/or family) and the diagnosis of the abscess with 566 if you are using ICD-9 and K61.0 if you are using ICD-10 codes.