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ICD-10 Guide
ICD-10 CodesK60.2

K60.2

Billable

Anal fissure, unspecified

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/06/2025

Code Description

ICD-10 K60.2 is a billable code used to indicate a diagnosis of anal fissure, unspecified.

Key Diagnostic Point:

Anal fissure, unspecified (K60.2) refers to a tear in the lining of the anal canal, which can cause significant pain and discomfort during bowel movements. The anal canal is a crucial part of the digestive system, serving as the exit point for stool. Anal fissures can occur due to various factors, including trauma from passing hard stools, prolonged diarrhea, or anal intercourse. Clinically, patients may present with sharp pain during defecation, bright red blood on the stool or toilet paper, and sometimes itching or irritation around the anus. Disease progression can lead to chronic fissures if not treated, which may require more invasive interventions. Diagnostic considerations include a thorough history and physical examination, often supplemented by anoscopy to visualize the fissure. It is essential to differentiate between acute and chronic fissures, as treatment approaches may vary significantly. The unspecified nature of K60.2 indicates that the fissure has not been classified as acute or chronic, which may impact treatment decisions and coding specificity.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Diagnostic complexity: Moderate, as it requires differentiation from other anal conditions.
  • Treatment complexity: Moderate, with options ranging from conservative management to surgical intervention.
  • Documentation requirements: Requires clear documentation of symptoms, examination findings, and treatment plans.
  • Coding specificity: Medium, as it lacks detail on the type of fissure.

Audit Risk Factors

  • Common coding errors: Misclassification of acute vs. chronic fissures.
  • Documentation gaps: Incomplete records regarding the nature and treatment of the fissure.
  • Billing challenges: Potential denials due to lack of specificity in documentation.

Specialty Focus

Medical Specialties

Gastroenterology

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Colorectal Surgery

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Related ICD-10 Codes

Related CPT Codes

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

Anal fissures can significantly impact patient quality of life, leading to pain, anxiety about bowel movements, and potential complications if left untreated. The prevalence of anal fissures varies, with an estimated 1 in 5 adults experiencing this condition at some point in their lives. Understanding the epidemiology of anal fissures can help healthcare providers implement preventive measures and improve patient education. Quality measures may include tracking the resolution of symptoms and the effectiveness of treatment protocols, which can ultimately lead to better healthcare utilization patterns.

ICD-9 vs ICD-10

Anal fissures can significantly impact patient quality of life, leading to pain, anxiety about bowel movements, and potential complications if left untreated. The prevalence of anal fissures varies, with an estimated 1 in 5 adults experiencing this condition at some point in their lives. Understanding the epidemiology of anal fissures can help healthcare providers implement preventive measures and improve patient education. Quality measures may include tracking the resolution of symptoms and the effectiveness of treatment protocols, which can ultimately lead to better healthcare utilization patterns.

Reimbursement & Billing Impact

reimbursement considerations include ensuring that the documentation aligns with the diagnosis and that any procedures performed are appropriately coded. Denials may occur if the documentation does not clearly support the diagnosis or if there is a lack of specificity in the coding. Best practices include regular audits of documentation and coding practices to minimize errors and ensure compliance with payer requirements.

Resources

Clinical References

  • •
    ICD-10 Official Guidelines for K00-K99
  • •
    Clinical Documentation Requirements

Coding & Billing References

  • •
    ICD-10 Official Guidelines for K00-K99
  • •
    Clinical Documentation Requirements

Frequently Asked Questions

What specific conditions are covered by K60.2?

K60.2 covers unspecified anal fissures, which may include acute or chronic fissures that have not been clearly defined. It is important to document the clinical presentation to support the diagnosis.

When should K60.2 be used instead of related codes?

K60.2 should be used when the type of anal fissure (acute or chronic) is not specified in the clinical documentation. If the fissure type is known, the more specific codes K60.0 or K60.1 should be utilized.

What documentation supports K60.2?

Documentation should include a detailed history of symptoms, physical examination findings, and any treatments attempted. Anoscopy findings, if performed, should also be documented to support the diagnosis.