Gastro-esophageal reflux disease with esophagitis, with bleeding
ICD-10 K21.01 is a billable code used to indicate a diagnosis of gastro-esophageal reflux disease with esophagitis, with bleeding.
Gastro-esophageal reflux disease (GERD) with esophagitis and bleeding is a condition characterized by the backward flow of stomach contents into the esophagus, leading to inflammation of the esophageal lining (esophagitis) and, in severe cases, bleeding. Clinically, patients may present with symptoms such as heartburn, regurgitation, chest pain, and difficulty swallowing. The anatomy involved includes the lower esophageal sphincter (LES), which normally prevents reflux, and the esophagus itself, which can become damaged due to the acidic content. Over time, chronic GERD can lead to complications such as Barrett's esophagus and esophageal strictures. Diagnostic considerations include endoscopy to visualize the esophagus and biopsy to assess for inflammation or dysplasia. The presence of bleeding indicates a more severe form of esophagitis, necessitating prompt medical evaluation and intervention to prevent further complications.
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
Standard ICD-10-CM documentation requirements apply
Various clinical presentations within this specialty area
Follow specialty-specific billing guidelines
K21.01 covers gastro-esophageal reflux disease specifically with esophagitis and the presence of bleeding. This includes cases where the esophagus is inflamed due to chronic acid exposure, leading to ulceration and bleeding.
K21.01 should be used when there is clear documentation of GERD accompanied by esophagitis and evidence of bleeding. If there is no esophagitis or bleeding, other codes such as K21.00 should be considered.
Documentation should include clinical notes detailing the patient's symptoms, results from endoscopic examinations, biopsy results, and any treatment plans that address the esophagitis and bleeding.
