Crohn's disease of small intestine with fistula

This code identifies a chronic inflammatory bowel disease specifically affecting the small intestine, characterized by transmural inflammation and the presence of a fistula. A fistula is an abnormal connection or tract that forms between two organs, or between an organ and the skin, as a complication of the inflammatory process.

Assign this code when documentation confirms a diagnosis of Crohn's disease localized to the small intestine, and a fistula is explicitly noted as a complication. This includes enteroenteric, enterocutaneous, enterovesical, or other fistulas originating from the small bowel due to Crohn's. Supporting documentation should clearly specify the location of the Crohn's and the presence and type of fistula.

• Ensure the documentation specifies "small intestine" as the affected site for Crohn's disease, not just "Crohn's disease with fistula."
• Differentiate from Crohn's disease of the large intestine or other sites with fistula, which would use different subcategories.
• Always review operative reports, endoscopy findings, and physician notes for explicit mention of both the small bowel involvement and the fistula.