Anal spasm
ICD-10 K59.4 is a billable code used to indicate a diagnosis of anal spasm.
Anal spasm, classified under K59.4, refers to involuntary contractions of the anal sphincter muscles, which can lead to significant discomfort and pain during bowel movements. This condition is often associated with underlying gastrointestinal disorders such as irritable bowel syndrome (IBS), anal fissures, or rectal prolapse. The anatomy involved includes the anal sphincter complex, which consists of the internal and external anal sphincters, both of which play crucial roles in maintaining continence and facilitating defecation. Disease progression can vary; while some patients may experience intermittent symptoms, others may suffer from chronic anal spasms that can severely impact quality of life. Diagnostic considerations include a thorough patient history, physical examination, and potentially additional tests such as anorectal manometry to assess sphincter function. It is essential to differentiate anal spasm from other causes of anal pain, such as hemorrhoids or infections, to ensure appropriate management.
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
K59.4 specifically covers anal spasm, which may occur in conjunction with conditions like IBS, anal fissures, or rectal pain syndromes. It is characterized by painful contractions of the anal sphincter, often exacerbated by bowel movements.
K59.4 should be used when the primary complaint is anal spasm without the presence of fissures or other identifiable anal pathologies. If fissures or other conditions are present, codes such as K59.3 should be considered.
Documentation should include a detailed patient history, symptom description (including frequency and severity of spasms), and any relevant diagnostic tests. Notes from physical examinations that confirm the diagnosis of anal spasm are also essential.
