ICD-10 Coding for Gastroesophageal Reflux Disease without Esophagitis(K21.9)
Complete ICD-10-CM coding and documentation guide for Gastroesophageal Reflux Disease without Esophagitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gastroesophageal Reflux Disease without Esophagitis
K20-K31Primary Range
Diseases of esophagus, stomach and duodenum
This range includes GERD and related esophageal conditions.
Key Information: ICD-10 code for GERD without esophagitis
Essential facts and insights about Gastroesophageal Reflux Disease without Esophagitis
Primary ICD-10-CM Code for k219 icd 10
Decision Criteria
clinical Criteria
- Endoscopy confirms absence of esophagitis.
documentation Criteria
- Provider note must state 'GERD without esophagitis'.
Applicable To
- GERD without esophagitis
Excludes
- GERD with esophagitis (K21.0)
Clinical Validation Requirements
- Endoscopy showing no esophagitis
- pH monitoring confirming reflux without esophagitis
Code-Specific Risks
- Incorrectly coding GERD with esophagitis as K21.9
Coding Notes
- Ensure documentation explicitly states 'without esophagitis'.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Heartburn
R12Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Gastroesophageal Reflux Disease without Esophagitis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K21.9.
Impact
Clinical: May lead to inappropriate treatment., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims.
Mitigation Strategy
Require endoscopy results before coding.
Impact
Reimbursement: Incorrect coding may lead to reimbursement issues., Compliance: Non-compliance with coding guidelines., Data Quality: Affects accuracy of clinical data.
Mitigation Strategy
Verify endoscopy results before coding.
Impact
Coding GERD without proper confirmation.
Mitigation Strategy
Ensure documentation includes endoscopy results.
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 Disease without Esophagitis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gastroesophageal Reflux Disease without Esophagitis
Use these documentation templates to ensure complete and accurate documentation for Gastroesophageal Reflux Disease without Esophagitis. These templates include all required elements for proper coding and billing.
Confirmed GERD without esophagitis
Specialty: GastroenterologyRequired Elements
- Endoscopy findings
- Diagnosis confirmation
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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