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Gastroesophageal reflux disease (GERD) is a condition the 1 last update 29 May 2020 treated in a lot of doctors’ offices, so coding for this diagnosis deserves some careful attention.Gastroesophageal reflux disease (GERD) is a condition treated in a lot of doctors’ offices, so coding for this diagnosis deserves some careful attention.
What is it? GERD involves acid reflux that occurs frequently. When the valve separating the esophagus and stomach doesn’t work appropriately, the stomach acid can travel up the esophagus, the tube from the throat to the stomach. Treatment often involves lifestyle changes and medication, but procedures by surgeons are a possible option, too, such as fundoplication.
When documentation confirms GERD, you’ve got two codes to choose from in ICD-10-CM 2018:
The difference between the two is that K21.0 applies when the provider documents GERD with esophagitis. You also use K21.0 for the term “reflux esophagitis,” according to an inclusion note under the code in ICD-10-CM. Esophagitis is inflammation of the esophagus.
If there’s documentation that the patient does not have esophagitis, use K21.9. This code is also the one you use when GERD documentation doesn’t refer to esophagitis at all. ICD-10-CM confirms this by including esophageal reflux NOS under K21.9.
Tip: Both codes have an Excludes1 note for newborn esophageal reflux. So if you’re coding for that condition, use P78.83 (Newborn esophageal reflux).
When considering coding for GERD, watch both for times when coding signs and symptoms is appropriate and for times when the patient has GERD as well as additional issues.
Signs and symptoms example: Heartburn is related to GERD, but they aren’t one and the same. Only use the GERD diagnosis codes when documentation shows the provider diagnosed that specific condition. If the diagnosis is “heartburn,” then you should use R12 (Heartburn).
Additional issues examples: Patients with certain chronic conditions are more prone to GERD, so watch for documentation that diagnoses like asthma (J45.-) or obesity (E66.-) factored into the provider’s evaluation and treatment decisions.
GERD also may be associated with other conditions that the patient develops. For instance, GERD may lead to Barrett’s esophagus. When reporting this condition, you’ll choose from K22.70 (Barrett’s esophagus without dysplasia) and K22.71- (Barrett’s esophagus with dysplasia). For the latter subcategory, knowing the grade of dysplasia will let you choose the most specific code:
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Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.