What You Need to Know About New Anal Fistula Codes and CDI Requirements
Introduction
In the rapidly changing realm of medical billing and compliance, minor details can significantly impact payment. With the new CDI updates and changes in Anal Fistula coding, providers and billing teams must go beyond the basics to ensure that every claim is accurate, compliant, and audit ready. At Shoreline Medical Billing Company, we specialize in helping healthcare providers navigate these complexities with precision and efficiency.
This blog post explores the latest CDI updates and coding changes, including what anal fistulas are, the specific ICD-10 and CPT codes you need to know helping you to enhance your revenue cycle while maintaining compliance.
What is an Anal Fistula?
An anal fistula is a tunnel-like connection that develops from inside the upper part of the anus to the skin outside due to an infection or abscess in the anal gland, causing pain and discomfort. Even after the drainage of the fluid on its own or by surgery, the passage remains intact, forming the fistula.
What are the causes?
It is developed usually due to an inflammation or infection near the anal glands causing abscess, which remains like a fistula even after the pus drains out. The other causes may include
- Crohn’s disease, an inflammatory bowel disease.
- STIs (sexually transmitted infections) in the anal region.
- Tuberculosis affecting the anus.
- As a result of traumatic injury or surgery in anus.
What are the Common Symptoms of Anal fistula?
- Blood or pus-like fluid discharge close to the anus
- Discomfort and pain during bowel movements
- Redness and swelling near the anal region
- Recurrence of anal abscesses
What are its different types?
Based on their location, anal fistulas can be classified as:
- Intersphincteric fistula - where the internal anal sphincter muscle comes out through the space between the internal and external sphincter muscles.
- Transsphincteric fistula - which passes through both the layers of the anal sphincter muscles.
- A suprasphincteric fistula - passes through the internal sphincter and then goes around the external sphincter.
- Extrasphincteric fistula - which goes around both the sphincter muscles. This is a less common type usually originating from the rectum rather than the anus.
- Superficial anal fistula - which travels from the lower part of anal canal, below the anal glands, through the skin, bypassing the muscles.
How are they diagnosed?
- By Physical Examination
- Non-invasive Image testing like MRI
- Endoscopic ultrasound
- Fistulography
What are the treatment Options for Anal Fistulas?
Treament for anal fistula depends upon its complexity and location. Some of the options include:
- Fistulotomy - most common procedure used for simple fistulas.
- Seton Placement - which helps in draining out the pus in complicated or high-risk fistulas.
- Advancement Flap Surgery - is performed to maintain the continence when fistulas are present near the sphincter.
- LIFT Procedure (Ligation of Intersphincteric Fistula Tract) - procedure which involves minimal invasion and sphincter-sparing.
- Fibrin Glue or Plug - is a non-surgical method used in some selected cases.
Healthcare providers should always clearly mention the type, location and classification of the fistula, along with the detail explanation of the procedures followed. Always submit the report with proper documentation for accurate coding and reimbursement. We at Shoreline Medical Billing offer CDI support to ensure that all documentation meets the standards required, thereby reducing claim denials and improving revenue cycle efficiency.
What are the Recent coding changes and CDI updates for 2025?
New refinements have been added to the existing anal fistula codes along with added guidance on documentation specificity. Here is the list of things that must be looked upon while coding for anal fistulas.
According to the ICD-10-CM, the code K60.3 category has been expanded to include more specificity about the condition of the disease. These changes allow for better tracking of the disease progression and treatment outcomes.
| Code | Description |
|---|---|
| K60.311 | Anal fistula, simple, initial |
| K60.312 | Anal fistula, simple, persistent |
| K60.313 | Anal fistula, simple, recurrent |
| K60.319 | Anal fistula, simple, unspecified |
| K60.321 | Anal fistula, complex, initial |
| K60.322 | Anal fistula, complex, persistent |
| K60.323 | Anal fistula, complex, recurrent |
| K60.329 | Anal fistula, complex, unspecified |
Some common CPT Codes used
| CPT Code | Procedure |
|---|---|
| 46270 | Fistulotomy; simple single tract |
| 46275 | Fistulotomy; complex multiple tracts |
| 46280 | Fistulectomy complete |
| 46020 | Drainage of perirectal abscess |
| 46045 | Seton placement for fistula |
| 46080 | Anal sphincterotomy |
What are the best practices for CDI while coding for Anal fistula?
✔ Specify the Types and complexities
Always avoid usage of vague statement such as anal fistula present instead give a complete description of the types of fistulas present, mention their location and its complexities.
✔ Mention the treatment method and procedures
Use the correct CPT codes to mention the procedures used to treat the condition, such as surgery, seton placement, or glue or plug procedures.
✔ Include Comorbid conditions & associated diseases
If the fistula is formed due to a complication of another diagnosis, it should be mentioned in the record, along with other associated conditions like Crohn’s disease.
Conclusion
These updates enable healthcare providers a chance to improve the claim accuracy, reduce denials, and enhance patient care.
We at Shoreline Medical Billing Company assist practices adapt these changes with confidence by ensuring all documentation aligns with the latest CDI updates, and coding reflects the most accurate and compliant data possible.
Sharanya Rajmohan
Content Writer
Sharanya brings clarity to the complexities of medical billing and healthcare regulations. With a knack for turning industry shifts into straightforward, actionable insights, her blogs help readers stay informed without the jargon.
Are you ready to streamline your billing processes and stay ahead of coding changes? Contact Shoreline Medical Billing Company today.