Gastro-esophageal reflux disease with esophagitis, without bleeding
ICD-10 K21.00 is a billable code used to indicate a diagnosis of gastro-esophageal reflux disease with esophagitis, without bleeding.
Gastro-esophageal reflux disease (GERD) with esophagitis, without bleeding, is a chronic condition characterized by the backward flow of stomach contents into the esophagus, leading to inflammation of the esophageal lining. Clinically, patients may present with symptoms such as heartburn, regurgitation, chest pain, and difficulty swallowing. The anatomy involved includes the lower esophageal sphincter, which may be weakened or dysfunctional, allowing gastric acid to irritate the esophagus. Over time, untreated GERD can lead to complications such as esophagitis, Barrett's esophagus, and esophageal strictures. Diagnosis typically involves a combination of patient history, physical examination, and diagnostic tests such as endoscopy or pH monitoring. The presence of esophagitis is confirmed through endoscopic findings, which may show erythema, edema, or ulceration of the esophageal mucosa. Accurate diagnosis is crucial for effective management and to prevent progression to more severe conditions.
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
K21.00 covers gastro-esophageal reflux disease with esophagitis that does not involve bleeding. It is characterized by inflammation of the esophagus due to acid reflux, confirmed through endoscopic examination.
K21.00 should be used when the patient has GERD with esophagitis but without any evidence of bleeding. If bleeding is present, K21.01 should be selected instead.
Documentation should include a detailed patient history, symptom description, results from endoscopic evaluations showing esophagitis, and any treatment plans initiated.
