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ICD-10 Code K21.9

What is the code K21.9? K21.9 is a billable/specific ICD-10-CM code used for “Gastroesophageal reflux disease without esophagitis.” Detailed description of K21.9 This code is used to denote cases of gastroesophageal reflux disease (GERD) where there is no evidence of esophagitis. GERD is a condition in which stomach acids reflux or back up from the […]

What is the code K21.9?

K21.9 is a billable/specific ICD-10-CM code used for "Gastroesophageal reflux disease without esophagitis."

Detailed description of K21.9

This code is used to denote cases of gastroesophageal reflux disease (GERD) where there is no evidence of esophagitis. GERD is a condition in which stomach acids reflux or back up from the stomach into the esophagus, which can occur without the inflammation or erosion of the esophagus that characterizes esophagitis.

Symptoms commonly associated with K21.9

  • Heartburn
  • Acid regurgitation
  • Chest pain, especially after eating or when lying down
  • Difficulty swallowing
  • Chronic cough or wheezing
  • K21.0: Gastro-esophageal reflux disease with esophagitis
  • K21.1: Gastro-esophageal reflux disease with both esophagitis and esophageal stricture

Appropriate usage of K21.9 for billing

K21.9 should be used when the patient has been diagnosed with GERD without signs of esophagitis, based on the findings from endoscopic or other diagnostic evaluations.

Instructional guidelines for providers coding K21.9

Report K21. 9 when the provider documents GERD or GERD without esophagitis in the assessment portion of the note. 

Common pitfalls in coding with K21.9

  • Misdiagnosis or misclassification when esophagitis is present but not documented due to insufficient diagnostic investigation.
  • Overuse of K21.9 without proper diagnostic confirmation of GERD.

Key resources for K21.9 coding

Conclusion

K21.9 allows healthcare providers to accurately document cases of GERD where there is no esophagitis, guiding appropriate treatment strategies and ensuring accurate medical billing.

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