ICD-10 Coding for Esophageal Reflux(K21.00, K21.9)
Complete ICD-10-CM coding and documentation guide for Esophageal Reflux. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Esophageal Reflux
K20-K31Primary Range
Diseases of esophagus, stomach and duodenum
This range includes codes for esophageal conditions including GERD and its complications.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| K21.00 | Gastro-esophageal reflux disease with esophagitis, without bleeding | Use when GERD is confirmed with esophagitis but without bleeding. |
|
| K21.9 | Gastro-esophageal reflux disease without esophagitis | Use when GERD is diagnosed without esophagitis. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for GERD with esophagitis
Essential facts and insights about Esophageal Reflux
Primary ICD-10-CM Codes for esophageal reflux
Decision Criteria
clinical Criteria
- Endoscopic evidence of esophagitis
Applicable To
- GERD with esophagitis
Excludes
- Barrett's esophagus (K22.70)
Clinical Validation Requirements
- Endoscopic confirmation of esophagitis
- DeMeester score >14.7
Code-Specific Risks
- Incorrectly coding as K20.8 when GERD is confirmed.
Coding Notes
- Ensure endoscopic evidence of esophagitis is documented.
K21.9 - Gastro-esophageal reflux disease without esophagitis
Use when GERD is diagnosed without esophagitis.
Applicable To
- GERD without esophagitis
Excludes
- Esophagitis (K20.8)
Clinical Validation Requirements
- Typical reflux symptoms without endoscopic evidence of esophagitis
Coding Notes
Document typical symptoms and absence of esophagitis.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Esophageal Reflux to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K21.00.
Impact
Clinical: Inaccurate treatment planning., Regulatory: Potential audit issues., Financial: Incorrect billing and reimbursement.
Mitigation Strategy
Always specify presence or absence of esophagitis.
Impact
Reimbursement: Incorrect DRG assignment leading to potential underpayment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use K21.00 when GERD is confirmed with esophagitis.
Impact
Coding GERD without confirming esophagitis can lead to audit issues.
Mitigation Strategy
Ensure endoscopic evidence is documented.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Esophageal Reflux, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Esophageal Reflux
Use these documentation templates to ensure complete and accurate documentation for Esophageal Reflux. These templates include all required elements for proper coding and billing.
GERD with esophagitis
Specialty: GastroenterologyRequired Elements
- Symptoms
- Endoscopic findings
- Treatment response
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Esophageal Reflux? Ask your questions below.