Ulcerative colitis, unspecified with fistula

This code signifies a chronic inflammatory bowel disease affecting the large intestine, characterized by diffuse inflammation and ulceration, where the specific type of ulcerative colitis is not documented. A key feature is the presence of a fistula, an abnormal connection between two epithelialized surfaces, often between the bowel and another organ or the skin.

This code is appropriate when the medical record clearly documents a diagnosis of ulcerative colitis with an associated fistula, but the physician has not specified the extent or location of the ulcerative colitis (e.g., pancolitis, proctitis). Documentation must explicitly state "ulcerative colitis, unspecified" and "with fistula."

• Ensure documentation specifies "unspecified" ulcerative colitis; otherwise, a more specific code should be used.
• Do not use this code if the fistula is a complication of Crohn's disease; refer to codes in the K50 category.
• Always review the entire medical record for further specificity regarding the type or location of ulcerative colitis to avoid using an unspecified code when a more precise option is available.