Anal Sphincter Tear

A patient is admitted for delivery. The physician lists an anal sphincter tear as one of the final diagnoses; however, there is no mention of a third degree perineal laceration. What is the appropriate code for the anal sphincter tear? ...

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Note:  The following article synopsis was NOT provided by the AHA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article covers a coding update effective October 1, 2007 involving anal sphincter tears and related diagnosis classifications. It is relevant to coders working with obstetric, gynecologic, and gastrointestinal diagnosis coding, especially where delivery-related conditions, healed or old tears, and related associated conditions are involved. The article also notes organizational input from ACOG and discusses how the changes affect the classification of these diagnoses across related code categories.

Why This Topic Matters

These updates affect how anal sphincter tear diagnoses are classified in delivery and non-delivery settings, which can influence accurate diagnosis reporting and code selection in obstetric and related records.

Article Sections

  1. Coding update overview

    Introduces the diagnosis coding changes and the effective date. Summarizes the clinical context for why the update was needed.

  2. Related diagnosis categories and revisions

    Describes how the condition is addressed across existing diagnosis groupings and where related category changes were made. Includes references to associated obstetric and non-obstetric classifications.

  3. New code and exclusion notes

    Presents the newly added diagnosis classification and the related exclusion guidance within the revised structure. Highlights how the update distinguishes this condition from other closely related diagnoses.

  4. Coding question and example scenario

    Provides a brief case-style question about delivery-related documentation and the resulting code selection outcome. Illustrates the practical application of the update in a billing or coding context.

What You Will Learn

  • The scope of the anal sphincter tear diagnosis update
  • How the article organizes related delivery and non-delivery diagnosis categories
  • Which types of clinical documentation scenarios are addressed by the update
  • Why the update matters for obstetric and related coding workflows

Who Should Read This

  • Medical coders
  • Coding auditors
  • Obstetric documentation specialists
  • Clinical documentation improvement staff
  • Billing and reimbursement professionals

Codes Discussed

Code Ranges Discussed

  • ICD-9-CM: 664.0-664.9

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