ICD-10 Coding for Rectal Discomfort(K62.5, K64.9, K62.89, R10.2)
Complete ICD-10-CM coding and documentation guide for Rectal Discomfort. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Rectal Discomfort
K62-K64Primary Range
Diseases of anus and rectum
This range includes codes for conditions causing rectal discomfort, such as hemorrhoids and other anorectal disorders.
Symptoms and signs involving the digestive system and abdomen
This range includes symptom codes like pelvic and perineal pain, which may be used when the underlying cause of rectal discomfort is unspecified.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| K62.5 | Hemorrhage of anus and rectum | Use when there is active bleeding from the rectum. |
|
| K64.9 | Unspecified hemorrhoids | Use when hemorrhoids are present but not graded. |
|
| K62.89 | Other specified diseases of anus and rectum | Use for chronic anorectal pain with no specific diagnosis. |
|
| R10.2 | Pelvic and perineal pain | Use when rectal pain is present without a known cause. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for rectal discomfort
Essential facts and insights about Rectal Discomfort
Primary ICD-10-CM Codes for rectal discomfort
Decision Criteria
clinical Criteria
- Presence of visible rectal bleeding
Applicable To
- Active rectal bleeding
Excludes
- Anal fissure (K60.0)
Clinical Validation Requirements
- Hematochezia
- Visible hemorrhoids on exam
Code-Specific Risks
- Incorrectly using for occult bleeding
Coding Notes
- Ensure documentation specifies active bleeding.
K64.9 - Unspecified hemorrhoids
Use when hemorrhoids are present but not graded.
Applicable To
- Hemorrhoids with unspecified grade
Excludes
- Thrombosed hemorrhoids (K64.3)
Clinical Validation Requirements
- Palpable hemorrhoids
- Pain worsened by straining
Coding Notes
Document the absence of thrombosis if using K64.9.
K62.89 - Other specified diseases of anus and rectum
Use for chronic anorectal pain with no specific diagnosis.
Applicable To
- Functional anorectal pain
Excludes
- Proctitis (K51.219)
Clinical Validation Requirements
- Chronic pain >3 months
- Tenderness on rectal traction
Coding Notes
Ensure chronicity is documented.
R10.2 - Pelvic and perineal pain
Use when rectal pain is present without a known cause.
Applicable To
- Isolated rectal pain
Excludes
- Pain due to specific conditions
Clinical Validation Requirements
- Normal imaging
- Absence of structural pathology
Coding Notes
Document exclusion of other causes.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Rectal Discomfort to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K62.5.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Increased risk of audits and penalties., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Regular training on code specificity., Use decision support tools for code selection.
Impact
Reimbursement: Incorrect code may lead to lower reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use R19.5 for occult blood in stool.
Impact
Reimbursement: May affect DRG assignment and reimbursement., Compliance: Potential audit risk for unspecified coding., Data Quality: Lack of specificity in clinical data.
Mitigation Strategy
Document the grade or reason for unspecified status.
Impact
Frequent use of unspecified codes may trigger audits.
Mitigation Strategy
Ensure documentation supports specific code selection.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Rectal Discomfort, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Rectal Discomfort
Use these documentation templates to ensure complete and accurate documentation for Rectal Discomfort. These templates include all required elements for proper coding and billing.
Chronic rectal pain evaluation
Specialty: GastroenterologyRequired Elements
- Pain characterization
- Physical exam findings
- Diagnostic test results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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