Find comprehensive information on perianal abscess diagnosis, including clinical documentation, ICD-10 codes (K61.0, K61.2, K61.3), SNOMED CT concepts, and treatment options. Learn about perirectal abscess symptoms, causes, differential diagnosis, and surgical drainage procedures. This resource provides valuable insights for healthcare professionals, medical coders, and patients seeking information on perianal abscess management and coding guidelines. Explore relevant medical terminology, clinical findings, and best practices for accurate documentation and coding of this condition.
Also known as
Perianal abscess
Abscess located around the anus.
Cutaneous abscess, furuncle, and carbuncle
Skin infections involving localized collections of pus.
Anal and rectal fissures and fistulas
Tears or abnormal passages in the anal or rectal area.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the perianal abscess associated with anal fistula?
Yes
Code K60.3 Anal fistula with abscess
No
Is the abscess recurrent?
When to use each related code
| Description |
|---|
| Perianal Abscess |
| Anorectal Fistula |
| Pilonidal Cyst |
Coding perianal abscess without specifying location (e.g., ischiorectal, perirectal) can lead to rejected claims and inaccurate severity reflection.
Miscoding complex perianal abscesses, such as those with fistula or requiring extensive drainage, can lead to underpayment and compliance issues.
Insufficient documentation of abscess size, location, and associated conditions can lead to coding errors and impact quality reporting and reimbursement.
Patient presents with complaints consistent with perianal abscess. Symptoms include perirectal pain, anal pain, rectal pain, swelling, tenderness, and erythema in the perianal region. Patient may also report purulent drainage, fever, chills, and difficulty with defecation. Physical examination reveals a fluctuant, tender mass palpable in the perianal area. Differential diagnoses considered include anal fistula, pilonidal cyst, hidradenitis suppurativa, and Crohn's disease. Diagnosis of perianal abscess is confirmed by physical examination findings. Treatment plan includes incision and drainage of the abscess under local anesthesia. Wound care instructions provided, including sitz baths and regular dressing changes. Patient education regarding perianal abscess symptoms, causes, treatment, and potential complications such as fistula formation provided. Follow-up appointment scheduled to monitor healing and assess for any recurrence or development of an anal fistula. ICD-10 code K61.0 and CPT codes for incision and drainage (e.g., 46040, 46045) will be used for billing and coding purposes depending on the complexity of the procedure. Patient advised to return to the clinic if symptoms worsen or new symptoms develop.