ICD-10 Coding for Gastro-esophageal Reflux Disease with Esophagitis(K21.00, K21.01)
Complete ICD-10-CM coding and documentation guide for Gastro-esophageal Reflux Disease with Esophagitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gastro-esophageal Reflux Disease with Esophagitis
K20-K31Primary Range
Diseases of esophagus, stomach and duodenum
This range includes conditions affecting the esophagus, such as GERD with esophagitis.
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. |
|
| K21.01 | Gastro-esophageal reflux disease with esophagitis, with bleeding | Use when GERD is confirmed with esophagitis and active bleeding. |
|
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 Gastro-esophageal Reflux Disease with Esophagitis
Primary ICD-10-CM Codes for gastro-esophageal reflux disease with esophagitis
Decision Criteria
clinical Criteria
- Endoscopic evidence of esophagitis without bleeding
documentation Criteria
- Biopsy confirming reflux esophagitis
Clinical Validation Requirements
- Endoscopic evidence of esophagitis
- Biopsy confirming reflux esophagitis
Code-Specific Risks
- Incorrectly coding as K21.9 when esophagitis is present
Coding Notes
- Ensure endoscopic findings are documented to support esophagitis diagnosis.
K21.01 - Gastro-esophageal reflux disease with esophagitis, with bleeding
Use when GERD is confirmed with esophagitis and active bleeding.
Applicable To
- GERD with esophagitis and bleeding
Excludes
- Barrett's esophagus (K22.70-K22.719)
Clinical Validation Requirements
- Endoscopic evidence of esophagitis with bleeding
- Documented drop in hemoglobin
Coding Notes
Ensure documentation of bleeding is present.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Diaphragmatic hernia without obstruction or gangrene
K44.9Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Other esophagitis
K20.8Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Gastro-esophageal Reflux Disease with Esophagitis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K21.00.
Impact
Clinical: May lead to incorrect diagnosis., Regulatory: Increases risk of audit issues., Financial: Potential for denied claims.
Mitigation Strategy
Ensure biopsy results are included in the patient's record., Verify documentation before coding.
Impact
Reimbursement: May result in lower reimbursement due to lack of specificity., Compliance: Increases risk of audit failure., Data Quality: Leads to inaccurate clinical data.
Mitigation Strategy
Ensure endoscopic findings are documented to support esophagitis diagnosis.
Impact
Inadequate documentation of bleeding can lead to audit issues.
Mitigation Strategy
Ensure all instances of bleeding are clearly documented in the patient's record.
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 Gastro-esophageal Reflux Disease with Esophagitis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gastro-esophageal Reflux Disease with Esophagitis
Use these documentation templates to ensure complete and accurate documentation for Gastro-esophageal Reflux Disease with Esophagitis. These templates include all required elements for proper coding and billing.
Gastroenterology H&P
Specialty: GastroenterologyRequired Elements
- History of present illness
- Endoscopic findings
- Biopsy results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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