Q43.6

Q43.6: Congenital fistula of rectum and anus

Billable / specific codeICD-10-CMPOA exempt

Q43.6 is a billable, specific ICD-10-CM code for congenital fistula of rectum and anus. It is valid for submission on a claim.

Check Q43.6 with the rest of the claim: free scrubber

Excludes1: never code together

These conditions cannot occur together. Billing both on the same encounter is a denial.

congenital fistula of anus with absence, atresia and stenosis (Q42.2)
congenital fistula of rectum with absence, atresia and stenosis (Q42.0)
congenital rectovaginal fistula (Q52.2)
congenital urethrorectal fistula (Q64.73)
pilonidal fistula or sinus (L05.-)

Other codes that can never be billed with Q43.6

Their own Excludes1 notes name this code, so the conflict is not listed above.

K60.3Anal fistula
K60.4Rectal fistula
K60.5Anorectal fistula

Risk adjustment

No CMS-HCC V28 category: this code does not change a RAF score.

Medicare coverage

Q43.6 is named in 3 Medicare coverage policies: 3 listing it as supporting medical necessity. Which one applies depends on your Medicare contractor.

A56421Billing and Coding: CT of the Abdomen and Pelvis
A56456Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
A56632Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

Alphabetic index entries that lead here

Fistula›anus, anal›congenital
Fistula›fecal›congenital
Fistula›rectum›congenital

Code history

Unchanged in every release from FY2024 to FY2027.