Understanding Gastroesophageal Reflux Disease and ICD-10-CM Coding

August 22nd, 2023 - Aimee Wilcox

GERD stands for Gastroesophageal Reflux Disease, a chronic condition where stomach acid flows back into the esophagus, causing a range of symptoms, such as heartburn, regurgitation, chest pain, difficulty swallowing, and a chronic cough. GERD occurs when the lower esophageal sphincter (LES), a muscular ring that normally prevents the backflow of stomach acid, becomes weak or relaxes inappropriately, allowing the backward flow of stomach acid and contents into the esophagus. Stomach acid is a highly acidic fluid produced by the cells that line the stomach walls. It is primarily made up of hydrochloric acid (HCI), but contains other substances like enzymes, mucus, and electrolytes. 

It's important to note that millions of people suffer from the symptoms of GERD on a daily basis, signifying that GERD is a very common condition being reported in medical records each day, so understanding what to look for in the documentation to support code selection for this disease is important. 

GERD may be identified as the underlying cause of other conditions, such as Barretts esophagitis, among other conditions. Barretts esophagitis is a condition where the normal lining of the esophagus is replaced by abnormal cells, usually from exposure to long-term acid reflux from GERD. These abnormal esophageal cells, if left unmonitored alongside a chronic GERD condition, can lead to dysplastic or cancerous changes, requiring more aggressive treatment. 

The ICD-10-CM code set is a medical coding and classification system used to report diseases, illnesses, injuries, symptoms, and other related health problems. Within this coding system is category K21.- Gastro-esophageal reflux disease,” which is further broken down into the following code options: 

  • K21.00 Gastro-esophageal reflux disease with esophagitis, without bleeding
  • K21.01 Gastro-esophageal reflux disease with esophagitis, with bleeding
  • K21.9 Gastro-esophageal reflux disease without esophagitis

GERD without esophagitis and without bleeding is the least severe stage of the disease reported with K21.9. If the medical record does not identify esophagitis (inflammation or irritation of the esophagus) or bleeding then K21.9 should be reported. 

Coders are aware that coding guidelines differ when coding records in inpatient versus  outpatient settings. According to the Official ICD-10-CM Coding Guidelines, when GERD is suspected, but not yet confirmed (e.g., differential diagnosis) in the inpatient setting, it may be reported as if it has been confirmed. However, in the outpatient setting, suspected, rule out, or differential diagnosis statements are not considered as confirmed diagnoses and cannot be assigned. When language is used to describe possible diagnoses in the outpatient setting, coders are instructed to report the patient’s symptoms instead; until a confirmed diagnosis is documented by the treating provider. 

To diagnose GERD, and of course rule out other conditions or associated conditions, healthcare providers may perform or order the following: 

  • Medical history: This includes a detailed history of when the patient’s symptoms began, such as heartburn, regurgitation, chest pain, or chronic cough as well as identifying any remedies the patient may have used with some success (e.g., over-the-counter antacids, digestive enzymes). Identifying the makeup of the patient’s diet, such as processed or greasy foods, large amounts of caffeine, or even gluten, can assist the provider in identifying patterns that may help identify the likelihood of GERD.
  • Physical examination: Examination of the throat, mouth, and dentition can provide additional evidence of GERD or rule out other causes of the patient’s symptoms.
    Esophagogastroduodenoscopy (EGD) or upper endoscopy: This procedure involves inserting a thin, flexible tube with a camera (endoscope) through the mouth and into the esophagus and stomach to visualize structures, mucosal linings, and possibly part of the small interesting where absorption occurs. It can help identify the presence of esophagitis, bleeding, ulcers, strictures, hiatal hernia, or other abnormalities.
  • Esophageal pH monitoring: This is a test that measures the acidity (pH) levels in the esophagus over a 24-hour period. A thin tube is placed through the nose or mouth and into the esophagus and then connected to a portable device and over the following 24 hours, the patient will journal any symptoms, dietary intake, and activities performed while the device records the various pH levels.
  • Esophageal manometry: This test measures the function and strength of the esophagus and LES by inserting a thin tube through the nose or mouth and into the esophagus. Once positioned in the esophagus, the patient is asked to swallow to allow it to measure the strength of the muscle contractions and coordination of the esophagus in its functionality.
  • Upper GI or Barium swallow: This test involves drinking liquid barium a contrast or barium sulfate suspension, which is a radiopaque substance used in imaging procedures to enhance vizualization of structures that are difficult to see in the gastrointestinal tract. Once the barium coats the lining of the esophagus, stomach, and upper part of the small intestine, X-rays are taken to look for any abnormalities.

Understanding the disease and how it is diagnosed, along with the definitions of key words in the code description allow coders to better understand what to look for in the documentation in order to assign the correct ICD-10-CM code. Of note, it is best to set internal policies on what portions of the medical record should be used to locate information for reporting chronic conditions or the details that provide better options for higher-specificity coding. 

Problem lists that are not updated or chronic conditions that were not addressed during the patient’s encounter are not good sources for coding and can lead to incorrect coding and inappropriate reimbursement either to the provider or payer (e.g., risk adjustment). Educating providers on clearly documenting all problems addressed during the encounter or those chronic conditions that while not treated, did have an impact on the provider’s treatment decisions for the problems that were addressed, is vital in promoting documentation that supports medical necessity and high-specificity code assignment. 



Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....

Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association