ICD-10 Coding for Reflux Oesophagitis(K21.00, K21.01)
Complete ICD-10-CM coding and documentation guide for Reflux Oesophagitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Reflux Oesophagitis
K20-K23Primary Range
Diseases of esophagus
This range includes conditions related to esophageal disorders, including reflux 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 present with esophagitis but no bleeding is documented. |
|
| K21.01 | Gastro-esophageal reflux disease with esophagitis, with bleeding | Use when GERD is present with esophagitis and active bleeding is documented. |
|
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 reflux oesophagitis
Essential facts and insights about Reflux Oesophagitis
Primary ICD-10-CM Codes for reflux oesophagitis
Decision Criteria
clinical Criteria
- Presence of erosive changes on endoscopy
Clinical Validation Requirements
- Endoscopy showing erosive esophagitis
- Biopsy confirming basal cell hyperplasia
Code-Specific Risks
- Misclassification if bleeding is present but not documented
Coding Notes
- Ensure endoscopy findings are documented to support the diagnosis.
K21.01 - Gastro-esophageal reflux disease with esophagitis, with bleeding
Use when GERD is present with esophagitis and active bleeding is documented.
Applicable To
- Erosive esophagitis with bleeding
Excludes
- Barrett's esophagus (K22.70-K22.71)
Clinical Validation Requirements
- Endoscopy showing erosive esophagitis with bleeding
- Documentation of hematemesis or melena
Coding Notes
Document the source and extent of bleeding to support the code.
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.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Reflux Oesophagitis 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 diagnosis and treatment planning., Regulatory: Potential non-compliance with coding standards., Financial: Loss of reimbursement for more severe cases.
Mitigation Strategy
Ensure thorough documentation of endoscopy findings, Verify bleeding status before coding
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Ensure endoscopy findings are documented to confirm esophagitis.
Impact
Inadequate documentation of bleeding in esophagitis cases.
Mitigation Strategy
Implement standardized templates for endoscopy reports.
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 Reflux Oesophagitis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Reflux Oesophagitis
Use these documentation templates to ensure complete and accurate documentation for Reflux Oesophagitis. These templates include all required elements for proper coding and billing.
Gastroenterology Consultation
Specialty: GastroenterologyRequired Elements
- Patient history
- Endoscopy findings
- Biopsy results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Reflux Oesophagitis? Ask your questions below.