2024 ICD-10-CM Diagnosis Code Q43.6

Approximate Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

• Anorectal fistula
• Anorectal fistula
• Anorectal fistula
• Anorectal fistula
• Congenital anoperineal fistula
• Congenital anorectal fistula due to high anorectal malformation
• Congenital anorectal fistula due to intermediate anorectal malformation
• Congenital anorectal fistula due to low anorectal malformation
• Congenital fecal fistula
• Congenital fistula of anus
• Congenital fistula of anus
• Congenital fistula of anus
• Congenital fistula of anus
• Congenital fistula of rectum
• Congenital fistula of rectum
• Congenital fistula of rectum
• Congenital fistula of rectum
• Congenital fistula of rectum and anus
• Congenital fistula of rectum and anus
• Congenital fistula of rectum and anus
• Congenital fistula of rectum and anus
• Enterocutaneous fistula

Q43.6 is grouped with Diagnostic Related Groups - MS-DRG Mapping

Diagnostic Related Groups (DRGs) are a classification system used to group together diagnosis codes for the purpose of reimbursement and healthcare management. DRGs are used to standardize the way hospitals and other providers are paid for inpatient services. In this system patients are grouped together based on their principal diagnosis in areas referred to as Major Diagnostic Categories (MDC). Once a patient is assigned a particular diagnostic category, providers receive a predetermined payment rate for the services rendered. This reimbursement rate is often fixed and is meant to cover the cost of care for that patient. Reimbursement is also affected by the relative weight of a diagnostic related group based on the severity of a patient's illness and the associated cost of care during hospitalization.

Diagnostic related groups encourage healthcare providers to focus on quality and efficiency in patient care while managing costs effectively. The diagnosis code is present in the following groups for version MS-DRG V41.0 applicable from 10/01/2023 through 09/30/2024.

MS-DRG	MS-DRG Title	MCD	Relative Weight
393	OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC	06	1.6196
394	OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC	06	0.9369
395	OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC	06	0.6475

The relative weight of a diagnostic related group determines the reimbursement rate based on the severity of a patient's illness and the associated cost of care during hospitalization.

Present on Admission (POA)

Q43.6 is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here.

CMS POA Indicator Options and Definitions

POA Indicator	Reason for Code	CMS will pay the CC/MCC DRG?
Y	Diagnosis was present at time of inpatient admission.	YES
N	Diagnosis was not present at time of inpatient admission.	NO
U	Documentation insufficient to determine if the condition was present at the time of inpatient admission.	NO
W	Clinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.	YES
1	Unreported/Not used - Exempt from POA reporting.	NO

Convert Q43.6 to ICD-9-CM

• ICD-9-CM Code: 751.5 - Intestinal anomaly NEC
  Approximate Flag - The approximate mapping means there is not an exact match between the ICD-10 and ICD-9 codes and the mapped code is not a precise representation of the original code.

Patient Education

Anal Disorders

The anus is the opening of the rectum through which stool passes out of your body. Problems with the anus are common. They include hemorrhoids, abscesses, fissures (cracks), and cancer.

You may be embarrassed to talk about your anal troubles. But it is important to let your doctor know, especially if you have pain or bleeding. The more details you can give about your problem, the better your doctor will be able to help you. Treatments vary depending on the particular problem.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases

[Learn More in MedlinePlus]

Fistulas

A fistula is an abnormal connection between two parts inside of the body. Fistulas may develop between different organs, such as between the esophagus and the windpipe or the bowel and the vagina. They can also develop between two blood vessels, such as between an artery and a vein or between two arteries.

Some people are born with a fistula. Other common causes of fistulas include:

• Complications from surgery
• Injury
• Infection
• Diseases, such as Crohn's disease or ulcerative colitis

Treatment depends on the cause of the fistula, where it is, and how bad it is. Some fistulas will close on their own. In some cases, you may need antibiotics and/or surgery.

[Learn More in MedlinePlus]

Rectal Disorders

The rectum is the lower part of your large intestine where your body stores stool. Problems with rectum are common. They include hemorrhoids, abscesses, incontinence and cancer.

Many people are embarrassed to talk about rectal troubles. But seeing your doctor about problems in this area is important. This is especially true if you have pain or bleeding. Treatments vary depending on the particular problem.

NIH: National Institute of Diabetes and Digestive and Kidney Diseases

[Learn More in MedlinePlus]

Code History

• FY 2024 - No Change, effective from 10/1/2023 through 9/30/2024
• FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
• FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
• FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
• FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
• FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
• FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
• FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
• FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016. This was the first year ICD-10-CM was implemented into the HIPAA code set.