ICD-10 Coding for Acid Reflux(K21.00, K21.01, K21.9)
Complete ICD-10-CM coding and documentation guide for Acid Reflux. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Acid Reflux
K20-K31Primary Range
Diseases of esophagus, stomach and duodenum
This range includes codes for GERD and related esophageal conditions.
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 no bleeding is present. |
|
| K21.01 | Gastro-esophageal reflux disease with esophagitis, with bleeding | Use when GERD is confirmed with esophagitis and bleeding is present. |
|
| 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 acid reflux
Essential facts and insights about Acid Reflux
Primary ICD-10-CM Codes for acid reflux
Decision Criteria
clinical Criteria
- Presence of erosive esophagitis confirmed by endoscopy
Applicable To
- Erosive esophagitis
Excludes
- Barrett's esophagus (K22.7)
Clinical Validation Requirements
- Endoscopy showing erosive esophagitis
- Los Angeles Grade A-B esophagitis
Code-Specific Risks
- Incorrect use without endoscopic confirmation
Coding Notes
- Ensure endoscopic evidence is documented.
K21.01 - Gastro-esophageal reflux disease with esophagitis, with bleeding
Use when GERD is confirmed with esophagitis and bleeding is present.
Applicable To
- GERD with bleeding
Excludes
- Barrett's esophagus (K22.7)
Clinical Validation Requirements
- Endoscopy showing bleeding
- Documented hemoglobin drop
Coding Notes
Ensure bleeding is documented with endoscopy or lab results.
K21.9 - Gastro-esophageal reflux disease without esophagitis
Use when GERD is diagnosed without esophagitis.
Applicable To
- GERD without esophagitis
Excludes
- Esophagitis (K20.-)
Clinical Validation Requirements
- Symptoms of GERD without endoscopic evidence of esophagitis
Coding Notes
Ensure no esophagitis is documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Acute bronchospasm
J98.01Differential 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 Acid 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: Misrepresentation of patient's condition, Regulatory: Potential audit issues, Financial: Denied claims
Mitigation Strategy
Verify endoscopic findings, Educate providers on documentation standards
Impact
Reimbursement: Claim denial due to lack of evidence, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate clinical data representation
Mitigation Strategy
Ensure endoscopic findings are documented before coding.
Impact
High risk of audit if GERD is coded without confirming esophagitis.
Mitigation Strategy
Require endoscopic documentation before coding.
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 Acid Reflux, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Acid Reflux
Use these documentation templates to ensure complete and accurate documentation for Acid Reflux. These templates include all required elements for proper coding and billing.
GERD with esophagitis
Specialty: GastroenterologyRequired Elements
- Patient symptoms
- Endoscopic findings
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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