2025 ICD-10-CM code K21.00
Gastro-esophageal reflux disease with esophagitis, without bleeding.
Medical necessity for treatment is established by the presence of symptoms and objective evidence of esophagitis, impacting the patient's quality of life or posing potential long-term health risks.Treatment aims to alleviate symptoms, prevent complications (e.g., stricture formation, Barrett's esophagus), and improve the patient's overall well-being.
Clinicians responsible for diagnosing and managing this condition include gastroenterologists, primary care physicians, and other specialists as needed.Responsibilities include taking a patient history, physical examination, ordering and interpreting diagnostic tests, and formulating a treatment plan.
- Diseases of the digestive system (K00-K95)
- K21.00 is a subcategory of K21 (Gastro-esophageal reflux disease), which falls under K20-K31 (Diseases of esophagus, stomach and duodenum).
In simple words: This code signifies a diagnosis of gastroesophageal reflux disease (GERD) where stomach acid irritates the esophagus, causing inflammation (esophagitis), but no bleeding is present.
Gastro-esophageal reflux disease with esophagitis, without bleeding.
Example 1: A 45-year-old male presents with heartburn, regurgitation, and difficulty swallowing.An upper endoscopy reveals inflammation in the esophagus, confirming GERD with esophagitis.There is no evidence of bleeding., A 28-year-old female experiences chronic cough and hoarseness. After further investigation, including an esophageal pH monitoring study, she is diagnosed with GERD with esophagitis, without bleeding. Her symptoms are attributed to the reflux of stomach acid irritating her throat., A 60-year-old patient with a history of Barrett's esophagus undergoes routine surveillance endoscopy.The procedure reveals active esophagitis related to GERD but no signs of bleeding or dysplasia.
Documentation should include details of symptoms (e.g., heartburn, regurgitation, chest pain, dysphagia), diagnostic findings (e.g., endoscopy report, pH monitoring results), and any associated complications or comorbidities.The absence of bleeding should be explicitly noted.
** For accurate coding, it is crucial to differentiate between GERD with esophagitis (K21.00, K21.010-K21.018) and GERD without esophagitis (K21.9).Refer to official ICD-10-CM coding guidelines for detailed instructions.
- Specialties:Gastroenterology, Internal Medicine, Family Medicine, Otolaryngology
- Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home