K62.81 Anal sphincter tear (healed) (nontraumatic) (old)

ICD10CM code

#### Name of the Condition
- Anal Sphincter Tear (Healed) (Nontraumatic) (Old)
- ICD-10 Code: K62.81

#### Summary
An anal sphincter tear refers to a healed injury of the muscles around the anus, which in this context is nontraumatic and occurred some time ago (old). Though healed, it may still be of clinical significance during examination.

#### Causes
- Nontraumatic causes can include conditions like childbirth, chronic constipation, hemorrhoids, or a history of anal surgery.

#### Risk Factors
- Pregnancy and vaginal childbirth
- Chronic constipation or straining during bowel movements
- History of anal or colorectal surgery
- Advanced age which may lead to tissue weakening

#### Symptoms
- Although healed, patients may have a history of symptoms such as pain, irritation, or discomfort during bowel movements. However, no active symptoms are typically present if the tear is fully healed.

#### Diagnosis
- Physical examination by a healthcare provider
- Patient history to understand past circumstances that might have led to an anal sphincter tear

#### Treatment Options
- For a healed tear, treatment may not be necessary unless there are complications or recurrent issues.
- Maintaining soft stools through diet and hydration can prevent future strain.

#### Prognosis and Follow-Up
- The prognosis for a healed tear is generally good. Regular follow-ups may not be necessary unless the patient experiences recurrent issues.
- Patients are advised to maintain habits that facilitate smooth bowel movements.

#### Complications
- Rarely, a healed tear could lead to issues such as anal fissures if bowel movements remain difficult.
- Long-term weakening of the sphincter muscle if the original cause is not addressed.

#### Lifestyle & Prevention
- High-fiber diet and adequate hydration to maintain soft stools
- Regular exercise to promote overall digestive health
- Avoiding straining during bowel movements

#### When to Seek Professional Help
- New symptoms such as persistent pain, bleeding, or change in bowel habits should prompt a visit to a healthcare provider.

#### Additional Resources
- American Society of Colon and Rectal Surgeons: [Website](https://www.fascrs.org/)
- Mayo Clinic: Anal fissures [Information Page](https://www.mayoclinic.org/diseases-conditions/anal-fissure/)

#### Tips for Medical Coders
- Ensure the condition is documented as healed, nontraumatic, and old to accurately use the ICD code K62.81.
- Verify that there are no active symptoms that might warrant coding under an active or acute condition.

Similar Codes