ICD-10 Coding for Gastroesophageal Reflux Disorder(K21.00, K21.01, K21.9)
Complete ICD-10-CM coding and documentation guide for Gastroesophageal Reflux Disorder. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gastroesophageal Reflux Disorder
K20-K31Primary Range
Diseases of esophagus, stomach and duodenum
This range includes conditions related to the esophagus, including GERD and its complications.
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 bleeding. |
|
| K21.9 | Gastro-esophageal reflux disease without esophagitis | Use when GERD symptoms are present but no esophagitis is confirmed. |
|
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 Disorder
Primary ICD-10-CM Codes for gastroesophageal reflux disorder
Decision Criteria
clinical Criteria
- Endoscopy confirms esophagitis without bleeding.
Applicable To
- GERD with esophagitis
Excludes
- Barrett's esophagus (K22.7)
Clinical Validation Requirements
- Endoscopy showing LA Grade A-D esophagitis
Code-Specific Risks
- Ensure esophagitis is documented; otherwise, use K21.9.
Coding Notes
- Ensure documentation specifies esophagitis without bleeding.
K21.01 - Gastro-esophageal reflux disease with esophagitis, with bleeding
Use when GERD is confirmed with esophagitis and bleeding.
Applicable To
- GERD with esophagitis and bleeding
Excludes
- Barrett's esophagus (K22.7)
Clinical Validation Requirements
- Endoscopy showing esophagitis with active bleeding
Coding Notes
Document both esophagitis and bleeding clearly.
K21.9 - Gastro-esophageal reflux disease without esophagitis
Use when GERD symptoms are present but no esophagitis is confirmed.
Applicable To
- GERD without esophagitis
Excludes
- Barrett's esophagus (K22.7)
Clinical Validation Requirements
- Typical GERD symptoms without endoscopic evidence
Coding Notes
Ensure no esophagitis is documented.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Gastro-esophageal reflux disease without esophagitis
K21.9Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Gastroesophageal Reflux Disorder 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: Claim denials or reduced reimbursement.
Mitigation Strategy
Verify endoscopy findings before coding., Educate staff on documentation standards.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate clinical data recording.
Mitigation Strategy
Ensure endoscopy results confirm esophagitis.
Impact
Inadequate documentation can lead to audits.
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 Gastroesophageal Reflux Disorder, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gastroesophageal Reflux Disorder
Use these documentation templates to ensure complete and accurate documentation for Gastroesophageal Reflux Disorder. These templates include all required elements for proper coding and billing.
GERD with esophagitis
Specialty: GastroenterologyRequired Elements
- Patient symptoms
- Endoscopy findings
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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