2025 ICD-10-CM code K62.81
(Active) Effective Date: N/A Diseases of the digestive system - Other diseases of intestines (K55-K64) Diseases of the digestive system (K00-K95) Feed
Healed nontraumatic anal sphincter tear (old). This condition refers to a tear in the anal sphincter muscle that has healed over time, was not caused by trauma, and is considered an old injury.
Medical necessity for the treatment of a healed anal sphincter tear depends on associated symptoms and functional impairments.For example, treatment for fecal incontinence related to the tear would be medically necessary.
Clinicians should document the complete history of the anal sphincter tear, including when it occurred, how it healed, and any ongoing symptoms, such as fecal incontinence. They should also evaluate and manage any complications resulting from the tear.
In simple words: This code signifies an old, healed tear in the ring of muscle (anal sphincter) that controls bowel movements. The tear wasn't caused by an injury.
Healed nontraumatic anal sphincter tear (old).A tear of the anus that is not due to trauma and has healed. Use additional code for any associated fecal incontinence (R15.-).Excludes2: anal fissure (K60.-); anal sphincter tear (healed) (old) complicating delivery (O34.7-); traumatic tear of anal sphincter (S31.831)
Example 1: A 50-year-old female presents with occasional fecal incontinence.Upon examination, a healed, non-traumatic anal sphincter tear is discovered. The tear is old and likely occurred during childbirth years ago.The code K62.81 is used, along with a code from the R15.- category for fecal incontinence., A 65-year-old male is undergoing a colonoscopy.The physician notes an old, healed anal sphincter tear.The patient reports no symptoms related to the tear.Code K62.81 is used. , A 30-year-old female patient had a previous anal sphincter tear during childbirth that has since healed. She now experiences fecal incontinence. K62.81 and a code for fecal incontinence (R15.-) are applied.
Documentation should clearly indicate the presence of the healed anal sphincter tear, that it's non-traumatic and old.Any associated symptoms, particularly fecal incontinence, should also be documented.
- Specialties:Gastroenterology, colorectal surgery, general surgery, proctology
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital