2025 ICD-10-CM code K21.0
(Active) Effective Date: N/A Revision Date: N/A Diseases of the digestive system - Diseases of esophagus, stomach and duodenum (K20-K31) Diseases of the digestive system (K00-K95) Feed
Gastro-esophageal reflux disease with esophagitis.
Symptoms must significantly impact the patient's quality of life or pose a risk of complications. Treatment aims to alleviate symptoms, prevent disease progression, and manage complications.
Diagnosis and treatment of gastroesophageal reflux disease (GERD) by a healthcare professional specializing in gastroenterology or internal medicine. Responsibilities include clinical evaluation (history and physical exam), diagnostic tests (endoscopy, pH monitoring), and management (lifestyle modifications, medications, surgery).
In simple words: This refers to heartburn with inflammation of the food pipe.
This code describes a condition where the contents of the stomach flow back into the esophagus, causing inflammation and irritation of the esophageal lining.
Example 1: A 45-year-old male presents with frequent heartburn, chest pain, and difficulty swallowing. An upper endoscopy reveals esophagitis, confirming GERD, so K21.0 is used., A 30-year-old female experiences chronic cough and hoarseness. After excluding other causes, a gastroenterologist diagnoses GERD with associated esophagitis, and documents K21.0., A 55-year-old patient with a history of GERD develops Barrett's esophagus. Regular endoscopic surveillance is coded with K21.0 to indicate the ongoing esophageal inflammation.
Symptoms (heartburn, regurgitation, chest pain, dysphagia), physical exam findings, endoscopic reports, biopsy results, pH monitoring studies, and treatment plan.
** Excludes newborn esophageal reflux (P78.83) and hiatus hernia (K44.-).
- Specialties:Gastroenterology, internal medicine, family medicine.
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center