Anal sphincter tear (healed) (nontraumatic) (old)
ICD-10 K62.81 is a billable code used to indicate a diagnosis of anal sphincter tear (healed) (nontraumatic) (old).
K62.81 refers to a healed anal sphincter tear that is nontraumatic and classified as an old injury. The anal sphincter is a complex structure composed of internal and external muscles that control the passage of stool. A tear in this area can lead to complications such as fecal incontinence, which may significantly impact a patient's quality of life. Clinically, patients may present with a history of prior anal trauma, childbirth, or surgical procedures that could have caused the initial injury. The progression of the condition may vary; while some patients may experience complete healing, others may have residual symptoms that require management. Diagnostic considerations include a thorough patient history, physical examination, and possibly imaging studies to assess the integrity of the anal sphincter. It is crucial to differentiate between acute and healed tears, as treatment approaches may differ significantly. Proper coding requires an understanding of the patient's history and the current status of the injury.
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
K62.81 specifically covers healed anal sphincter tears that are nontraumatic in nature. This may include tears resulting from childbirth or previous surgical interventions that have since healed but may still cause residual symptoms.
K62.81 should be used when the anal sphincter tear is confirmed to be healed and nontraumatic. If the tear is acute or associated with trauma, other codes such as K62.82 should be considered.
Documentation should include a detailed history of the anal sphincter tear, evidence of healing (such as physical examination findings), and any ongoing symptoms or treatments. Notes should clearly indicate the nontraumatic nature of the injury.
