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2025 ICD-10-CM code K60.0

Acute anal fissure.

Coding guidelines for K60.0 should align with the official ICD-10-CM guidelines.Ensure accurate documentation supports the diagnosis.Additional codes may be required to capture related findings like infections.

Modifiers may be applicable depending on the circumstances of the service. Consult current coding guidelines for specific modifier application rules.

Medical necessity for treatment of an acute anal fissure is established by the presence of significant pain, bleeding, and/or functional impairment. The severity of symptoms warrants appropriate medical intervention to relieve symptoms and prevent complications such as chronic fissures or infections.

The clinical responsibility for diagnosing and managing an acute anal fissure typically falls on a gastroenterologist, colorectal surgeon, or general practitioner.

IMPORTANT:This code may be linked to other codes depending on the associated symptoms and complications.For instance, if an infection is present, additional codes for the infection would be necessary.

In simple words: An acute anal fissure is a small tear in the skin around the anus that causes pain, bleeding, and sometimes itching. It's a relatively new problem, not a long-term one.

K60.0 in the ICD-10-CM coding system represents an acute anal fissure.This is a tear in the lining of the anus, typically causing pain, bleeding, and sometimes itching.The acute nature implies it is a recent occurrence, as opposed to a chronic, long-standing fissure.

Example 1: A 35-year-old patient presents with acute rectal pain and bright red bleeding after a bowel movement.Physical examination reveals a small tear in the anal canal, consistent with an acute anal fissure., A 28-year-old patient reports severe anal pain, especially during and after defecation, accompanied by bright red blood on the stool and some itching.A digital rectal examination confirms the presence of an acute anal fissure., A 50-year-old patient experiences recurrent episodes of severe anal pain and bleeding, now accompanied by a noticeable fissure visible during a routine check-up. Despite some prior conservative management attempts, the anal fissure recurs, indicative of an acute phase.

Detailed patient history including the onset, character, and duration of symptoms (pain, bleeding, itching).Findings from the physical examination, particularly digital rectal examination, confirming the presence of the fissure.Any relevant imaging studies (if performed) and results of laboratory tests (if any).Documentation of the treatment plan.

** Differentiate between acute and chronic anal fissures based on the duration of symptoms.Chronic fissures are typically defined as those lasting longer than 6-8 weeks.

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