ICD-10 Coding for Gastroesophageal Reflux Disease(K21.0, K21.9, K21.01)
Complete ICD-10-CM coding and documentation guide for Gastroesophageal Reflux Disease. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gastroesophageal Reflux Disease
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| K21.0 | Gastro-esophageal reflux disease with esophagitis | Use when endoscopy confirms esophagitis in GERD patients. |
|
| K21.9 | Gastro-esophageal reflux disease without esophagitis | Use when GERD symptoms are present but esophagitis is not confirmed. |
|
| K21.01 | Gastro-esophageal reflux disease with esophagitis and bleeding | Use when GERD is complicated by bleeding 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 Gastroesophageal Reflux Disease
Primary ICD-10-CM Codes for gastroesophageal reflux disease
Decision Criteria
clinical Criteria
- Endoscopic evidence of esophagitis
Applicable To
- Reflux esophagitis
Excludes
- Barrett's esophagus (K22.7)
Clinical Validation Requirements
- Endoscopic confirmation of esophagitis
Code-Specific Risks
- Incorrectly coding without endoscopic evidence
Coding Notes
- Ensure endoscopic findings are documented to support this code.
K21.9 - Gastro-esophageal reflux disease without esophagitis
Use when GERD symptoms are present but esophagitis is not confirmed.
Applicable To
- Non-erosive reflux disease (NERD)
Excludes
- Reflux esophagitis (K21.0)
Clinical Validation Requirements
- Symptoms of GERD without endoscopic evidence of esophagitis
Coding Notes
Document symptoms clearly to differentiate from other conditions.
K21.01 - Gastro-esophageal reflux disease with esophagitis and bleeding
Use when GERD is complicated by bleeding esophagitis.
Applicable To
- GERD with bleeding
Excludes
- Barrett's esophagus (K22.7)
Clinical Validation Requirements
- Endoscopic evidence of esophagitis with bleeding
Coding Notes
Ensure bleeding is documented in the clinical record.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Gastro-esophageal reflux disease without esophagitis
K21.9Functional dyspepsia
K30Gastrointestinal hemorrhage, unspecified
K92.2Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Gastroesophageal Reflux Disease to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K21.0.
Impact
Clinical: May lead to misdiagnosis or inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials or reduced reimbursement.
Mitigation Strategy
Use specific terms like 'erosive esophagitis', Document diagnostic test results
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Verify endoscopic findings and use K21.0 if esophagitis is present.
Impact
Using non-specific codes when detailed codes are available.
Mitigation Strategy
Regular training and audits of coding practices.
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 Gastroesophageal Reflux Disease, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gastroesophageal Reflux Disease
Use these documentation templates to ensure complete and accurate documentation for Gastroesophageal Reflux Disease. These templates include all required elements for proper coding and billing.
GERD with esophagitis
Specialty: GastroenterologyRequired Elements
- Symptom duration
- Endoscopy findings
- Presence of bleeding
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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