ICD-10 Coding for Gastric Reflux(K21.0, K21.9)
Complete ICD-10-CM coding and documentation guide for Gastric Reflux. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gastric Reflux
K20-K31Primary Range
Diseases of esophagus, stomach, and duodenum
This range includes conditions related to the esophagus and stomach, including GERD.
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 GERD is confirmed with esophagitis via endoscopy. |
|
| 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 gastric reflux
Essential facts and insights about Gastric Reflux
Primary ICD-10-CM Codes for gastric reflux
Decision Criteria
clinical Criteria
- Presence of esophagitis confirmed by endoscopy
Applicable To
- Reflux esophagitis
Excludes
- Barrett's esophagus (K22.7-)
Clinical Validation Requirements
- Endoscopic findings confirming esophagitis
- LA Classification A-D
Code-Specific Risks
- Incorrect use without documented esophagitis
Coding Notes
- Ensure esophagitis is documented via endoscopy.
K21.9 - Gastro-esophageal reflux disease without esophagitis
Use when GERD is diagnosed without esophagitis.
Applicable To
- GERD without esophagitis
Excludes
- Reflux esophagitis (K21.0)
Clinical Validation Requirements
- Symptoms of heartburn or regurgitation without endoscopic evidence of esophagitis
Coding Notes
Ensure absence of esophagitis is documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Helicobacter pylori as the cause of diseases classified elsewhere
B96.81Differential 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 Gastric Reflux to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K21.0.
Impact
Clinical: Misrepresentation of patient's condition, Regulatory: Potential audit issues, Financial: Claim denials
Mitigation Strategy
Ensure endoscopy is performed and documented, Use specific diagnostic terms
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Ensure esophagitis is confirmed via endoscopy before coding.
Impact
Auditors focus on the presence of documented esophagitis for K21.0.
Mitigation Strategy
Ensure all endoscopic findings are clearly 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 Gastric Reflux, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gastric Reflux
Use these documentation templates to ensure complete and accurate documentation for Gastric Reflux. These templates include all required elements for proper coding and billing.
GERD with esophagitis
Specialty: GastroenterologyRequired Elements
- Symptom description
- Endoscopy findings
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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