ICD-10 Coding for GERD with Esophagitis(K21.00, K21.01, K21.9)
Complete ICD-10-CM coding and documentation guide for GERD with Esophagitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to GERD with Esophagitis
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 with esophagitis is documented without bleeding. |
|
| K21.01 | Gastro-esophageal reflux disease with esophagitis, with bleeding | Use when GERD with esophagitis and bleeding is documented. |
|
| K21.9 | Gastro-esophageal reflux disease without esophagitis | Use when GERD is documented 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 GERD with esophagitis
Essential facts and insights about GERD with Esophagitis
Primary ICD-10-CM Codes for gerd esophagitis
Decision Criteria
clinical Criteria
- EGD shows esophagitis without bleeding.
Applicable To
- GERD with esophagitis
Excludes
- Eosinophilic esophagitis (K20.0)
Clinical Validation Requirements
- EGD findings showing esophagitis
- pH monitoring confirming acid reflux
Code-Specific Risks
- Incorrectly using K20.90 when GERD is present.
Coding Notes
- Ensure documentation specifies 'esophagitis' to use this code.
K21.01 - Gastro-esophageal reflux disease with esophagitis, with bleeding
Use when GERD with esophagitis and bleeding is documented.
Applicable To
- GERD with esophagitis and bleeding
Excludes
- Eosinophilic esophagitis (K20.0)
Clinical Validation Requirements
- EGD showing active bleeding
- Documentation of hematemesis or melena
Coding Notes
Bleeding must be clearly documented to use this code.
K21.9 - Gastro-esophageal reflux disease without esophagitis
Use when GERD is documented without esophagitis.
Applicable To
- GERD without esophagitis
Excludes
- Eosinophilic esophagitis (K20.0)
Clinical Validation Requirements
- Normal EGD
- Symptom relief with PPIs
Coding Notes
Ensure no esophagitis is documented to use this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Barrett’s esophagus without dysplasia
K22.70Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Eosinophilic esophagitis
K20.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting GERD with Esophagitis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K21.00.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with coding standards., Financial: Potential loss of reimbursement.
Mitigation Strategy
Ensure thorough review of EGD reports, Clarify documentation with providers
Impact
Reimbursement: Incorrect code may affect DRG assignment., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use K21.00 if GERD is documented.
Impact
Inadequate documentation may lead to audit findings.
Mitigation Strategy
Ensure detailed EGD findings are included in patient records.
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 GERD with Esophagitis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for GERD with Esophagitis
Use these documentation templates to ensure complete and accurate documentation for GERD with Esophagitis. These templates include all required elements for proper coding and billing.
GERD with esophagitis documentation
Specialty: GastroenterologyRequired Elements
- Symptoms
- EGD findings
- Biopsy results
- Treatment response
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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