Gastro-esophageal reflux disease
Chapter 11:Diseases of the digestive system
ICD-10 K21 is a used to indicate a diagnosis of gastro-esophageal reflux disease.
Gastro-esophageal reflux disease (GERD) is a chronic digestive condition characterized by the backward flow of stomach contents into the esophagus, leading to symptoms such as heartburn, regurgitation, and dysphagia. The anatomy involved primarily includes the lower esophageal sphincter (LES), which normally prevents reflux. In GERD, the LES may be weakened or relax inappropriately, allowing gastric acid to irritate the esophageal lining. Disease progression can lead to complications such as esophagitis, Barrett's esophagus, and esophageal strictures if left untreated. Diagnosis typically involves a combination of clinical history, symptom assessment, and may include endoscopy or pH monitoring to evaluate esophageal acid exposure. Treatment options range from lifestyle modifications and over-the-counter antacids to prescription medications like proton pump inhibitors (PPIs) and, in severe cases, surgical interventions such as fundoplication. Accurate diagnosis and management are crucial to prevent long-term complications associated with GERD.
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 covers gastro-esophageal reflux disease, including its subtypes such as K21.0 (reflux esophagitis) and K21.9 (GERD without esophagitis). It encompasses conditions where acid reflux leads to esophageal inflammation and other related symptoms.
K21 should be used when the primary diagnosis is GERD, particularly when symptoms are present. If the condition is related to other esophageal diseases, such as strictures or malignancies, other codes like K22 may be more appropriate.
Documentation should include a detailed patient history of symptoms, results from diagnostic tests (like endoscopy or pH monitoring), treatment plans, and any complications that arise from GERD. Follow-up notes indicating treatment efficacy are also crucial.
