help with dx code - the provider wants dx for recto-vaginal

SHobbs

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the provider wants dx for recto-vaginal fistula but the note states possible. What would the appropriate diagnosis for this be?

Vaginal Examination reveals: discharge present and is brown, stool . and malodorous . No radiation changes note; possible recto-vaginal fistula present.

Any advise is greatly appreciated :D
 

cblack712

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619.1 is the code for Rectovaginal fistual, however you can't code for possible. You would have to use the signs and symptoms. On the same hand though - the only time stool will be present in the vaginal canal is when there is a fistula, at this point I would get the physician to clarify or remove the possible.
Sorry I can't help more, I have been coding for a long time and don't understand why doctors will do that.
 
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