ICD-10 Coding for Reflux Esophagitis(K21.01, K21.00, K21.9)
Complete ICD-10-CM coding and documentation guide for Reflux Esophagitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Reflux Esophagitis
K20-K31Primary Range
Diseases of esophagus, stomach and duodenum
This range includes codes for esophageal conditions, including reflux esophagitis.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| K21.01 | Gastro-esophageal reflux disease with esophagitis, with bleeding | Use when GERD is present with esophagitis and active bleeding. |
|
| K21.00 | Gastro-esophageal reflux disease with esophagitis, without bleeding | Use when GERD is present with esophagitis but no bleeding. |
|
| K21.9 | Gastro-esophageal reflux disease without esophagitis | Use when GERD is present without evidence of 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 reflux esophagitis with bleeding
Essential facts and insights about Reflux Esophagitis
Primary ICD-10-CM Codes for reflux esophagitis
Decision Criteria
clinical Criteria
- Presence of esophagitis with bleeding
Clinical Validation Requirements
- Endoscopic evidence of esophagitis with bleeding
- Histological confirmation of esophagitis
Code-Specific Risks
- Misclassification if bleeding is not documented
Coding Notes
- Ensure bleeding is documented to use this code.
K21.00 - Gastro-esophageal reflux disease with esophagitis, without bleeding
Use when GERD is present with esophagitis but no bleeding.
Applicable To
- GERD with esophagitis without bleeding
Excludes
- Barrett's esophagus (K22.70-K22.719)
Clinical Validation Requirements
- Endoscopic evidence of esophagitis
- Histological confirmation of esophagitis
Coding Notes
Ensure esophagitis is documented without bleeding.
K21.9 - Gastro-esophageal reflux disease without esophagitis
Use when GERD is present without evidence of esophagitis.
Applicable To
- GERD without esophagitis
Excludes
- Barrett's esophagus (K22.70-K22.719)
Clinical Validation Requirements
- Negative endoscopy for esophagitis
Coding Notes
Ensure no evidence of esophagitis is documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential 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 Esophagitis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K21.01.
Impact
Clinical: Inaccurate clinical picture, Regulatory: Potential audit issues, Financial: Incorrect DRG assignment
Mitigation Strategy
Always document bleeding status if present
Impact
Reimbursement: Incorrect coding may lead to inappropriate DRG assignment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Verify endoscopic and histological findings to confirm esophagitis.
Impact
Failure to document esophagitis can lead to incorrect coding.
Mitigation Strategy
Implement mandatory documentation checks for 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 Reflux Esophagitis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Reflux Esophagitis
Use these documentation templates to ensure complete and accurate documentation for Reflux Esophagitis. These templates include all required elements for proper coding and billing.
Endoscopic confirmation of esophagitis
Specialty: GastroenterologyRequired Elements
- Endoscopy findings
- Histology results
- Symptoms
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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