Gastro-esophageal reflux disease without esophagitis
ICD-10 K21.9 is a billable code used to indicate a diagnosis of gastro-esophageal reflux disease without esophagitis.
Gastro-esophageal reflux disease (GERD) without esophagitis is a chronic digestive condition characterized by the backward flow of stomach contents into the esophagus, leading to symptoms such as heartburn, regurgitation, and chest pain. The anatomy involved includes the lower esophageal sphincter (LES), which normally prevents reflux, and the esophagus itself, which can become irritated due to the acidic nature of the gastric contents. In K21.9, the absence of esophagitis indicates that there is no inflammation of the esophagus, which can complicate the clinical picture. Disease progression may vary; while some patients experience intermittent symptoms, others may have persistent issues that affect their quality of life. Diagnostic considerations include a thorough patient history, symptom assessment, and potentially, esophageal pH monitoring or endoscopy to rule out esophagitis or other complications. Treatment typically involves lifestyle modifications, pharmacotherapy with proton pump inhibitors (PPIs), and in some cases, surgical intervention. Accurate coding is essential for appropriate management and reimbursement.
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
K21.9 covers gastro-esophageal reflux disease characterized by symptoms of reflux without any associated esophagitis. This includes patients who experience heartburn and regurgitation but do not show signs of inflammation in the esophagus.
K21.9 should be used when a patient presents with GERD symptoms but has been evaluated and found to have no esophagitis. If esophagitis is present, K21.0 should be used instead.
Documentation should include a detailed history of symptoms, any diagnostic tests performed (such as pH monitoring), and treatment plans. Evidence of the absence of esophagitis should also be clearly noted.
