Anal spasm

This code represents an involuntary, painful contraction of the anal sphincter muscles. It is often a symptom of an underlying anorectal condition rather than a primary diagnosis itself. Patients typically present with severe, intermittent rectal pain.

Assign this code when documentation explicitly states "anal spasm" or "proctalgia fugax" as a diagnosis. This code is appropriate when the spasm is the primary reason for the encounter or a significant co-morbidity. Supporting documentation should describe the patient's symptoms of anal pain and muscle contraction.

• Always look for and code any underlying cause of the anal spasm, such as hemorrhoids, fissures, or inflammatory bowel disease, as the primary diagnosis if identified.
• Do not use this code for general rectal pain without documented evidence of muscle spasm.
• Consider sequencing this code after a more definitive diagnosis if the spasm is a symptom of another condition.