ICD Code K56.41

ICD code K56.41 is fecal impaction, which refers to a condition where a large mass of stool becomes stuck in the colon or rectum, making it difficult or impossible to pass naturally.

1. Patient presents with a history of chronic or acute constipation.

2. Physical examination reveals a palpable mass in the abdomen or rectum.

3. Digital rectal examination confirms the presence of a hard, immovable mass of stool in the rectum.

4. Patient reports symptoms such as abdominal pain, bloating, nausea, or vomiting.

5. There is evidence of overflow diarrhea or liquid stool leakage around the impacted fecal mass.

6. Imaging studies (e.g., abdominal X-ray) demonstrate retained fecal material in the colon or rectum.

7. No evidence of mechanical bowel obstruction from other causes (e.g., tumor, volvulus).

8. Associated risk factors may include immobility, neurological impairment, use of constipating medications, or inadequate fluid/fiber intake.

Relevant CPT codes for ICD code K56.41 include:

- 45900: Removal of fecal impaction, manual, rectal

- 45905: Removal of foreign body from rectum; digital

- 46600: Anoscopy; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)

- 96372: Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (if medication is administered to aid in impaction resolution)

- 99201–99215: Evaluation and management (E/M) codes for office or outpatient visits, as appropriate for the encounter

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