ICD-10 Coding for Reflux Disease(K21.00, K21.01, K21.9, K22.71)
Complete ICD-10-CM coding and documentation guide for Reflux Disease. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Reflux Disease
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 no bleeding is present. |
|
| K21.01 | Gastro-esophageal reflux disease with esophagitis, with bleeding | Use when GERD is confirmed with esophagitis and bleeding is present. |
|
| K21.9 | Gastro-esophageal reflux disease without esophagitis | Use when GERD is diagnosed but esophagitis is not confirmed. |
|
| K22.71 | Barrett's esophagus with dysplasia | Use when Barrett's esophagus with dysplasia is confirmed by biopsy. |
|
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 Reflux Disease
Primary ICD-10-CM Codes for reflux disease
Decision Criteria
clinical Criteria
- Presence of esophagitis confirmed by endoscopy
Clinical Validation Requirements
- Endoscopy showing esophagitis without bleeding
Code-Specific Risks
- Risk of undercoding if bleeding is present but not documented.
Coding Notes
- Ensure endoscopy findings are documented to support esophagitis diagnosis.
K21.01 - Gastro-esophageal reflux disease with esophagitis, with bleeding
Use when GERD is confirmed with esophagitis and bleeding is present.
Applicable To
- GERD with esophagitis and bleeding
Excludes
- Barrett's esophagus (K22.70-K22.71)
Clinical Validation Requirements
- Endoscopy showing esophagitis with bleeding
- Clinical signs of bleeding such as hematemesis
Coding Notes
Document bleeding explicitly to support this code.
K21.9 - Gastro-esophageal reflux disease without esophagitis
Use when GERD is diagnosed but esophagitis is not confirmed.
Applicable To
- GERD without esophagitis
Excludes
- GERD with esophagitis (K21.00-K21.01)
Clinical Validation Requirements
- Clinical diagnosis of GERD without endoscopic confirmation of esophagitis
Coding Notes
Ensure lack of esophagitis is documented.
K22.71 - Barrett's esophagus with dysplasia
Use when Barrett's esophagus with dysplasia is confirmed by biopsy.
Applicable To
- Barrett's esophagus with dysplasia
Excludes
- GERD without Barrett's (K21.00-K21.9)
Clinical Validation Requirements
- Biopsy confirming Barrett's esophagus with dysplasia
Coding Notes
Document biopsy results to support this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Acute bronchospasm
J98.01Differential 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 Reflux Disease to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K21.00.
Impact
Clinical: Inaccurate clinical picture of patient's condition., Regulatory: Non-compliance with coding standards., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Ensure thorough documentation of all clinical findings.
Impact
Reimbursement: May lead to lower reimbursement due to unspecified coding., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Query provider to confirm presence of esophagitis and use K21.00 or K21.01 as appropriate.
Impact
Using K21.9 when more specific codes apply.
Mitigation Strategy
Ensure documentation supports specific code selection.
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 Reflux Disease, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Reflux Disease
Use these documentation templates to ensure complete and accurate documentation for Reflux Disease. These templates include all required elements for proper coding and billing.
GERD with esophagitis
Specialty: GastroenterologyRequired Elements
- Chief complaint
- Endoscopy findings
- Presence of bleeding
- Biopsy results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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