ICD-10 Coding for History of GERD(Z87.11)
Complete ICD-10-CM coding and documentation guide for History of GERD. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of GERD
Z87.1-Z87.19Primary Range
Personal history of diseases of the digestive system
This range includes codes for documenting a patient's history of digestive system diseases, including GERD.
Key Information: ICD-10 code for history of GERD
Essential facts and insights about History of GERD
Primary ICD-10-CM Code for history of gerd
Decision Criteria
clinical Criteria
- Patient has no current GERD symptoms and past records show resolution.
Clinical Validation Requirements
- Documentation of resolved GERD with no current symptoms
- Past treatment records indicating resolution
- Surgical history such as fundoplication
Code-Specific Risks
- Incorrectly coding active GERD as history
- Lack of documentation for resolution
Coding Notes
- Ensure documentation clearly states GERD is resolved.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Long-term (current) use of proton pump inhibitors
Z79.4Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of GERD to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z87.11.
Impact
Clinical: Misrepresents patient's current health status., Regulatory: Non-compliance with coding guidelines., Financial: Potential for incorrect billing.
Mitigation Strategy
Ensure thorough review of patient history, Confirm resolution with the patient
Impact
Reimbursement: May result in incorrect billing and reimbursement issues., Compliance: Could lead to compliance issues with coding standards., Data Quality: Affects the accuracy of patient records.
Mitigation Strategy
Verify current symptoms and treatment status before coding.
Impact
Using Z87.11 for active GERD cases.
Mitigation Strategy
Regular training on coding guidelines and verification of patient status.
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 History of GERD, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of GERD
Use these documentation templates to ensure complete and accurate documentation for History of GERD. These templates include all required elements for proper coding and billing.
Resolved GERD in a primary care setting
Specialty: Primary CareRequired Elements
- Past Medical History
- Resolution Date
- Current Symptom Status
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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