2025 ICD-10-CM code K21.01
Gastro-esophageal reflux disease with esophagitis, with bleeding.
Medical necessity for K21.01 is established by the presence of signs and symptoms of GERD, such as heartburn and regurgitation, in conjunction with endoscopic evidence of esophagitis and bleeding. The bleeding may manifest as hematemesis, melena, or anemia.
Diagnosis and treatment of gastroesophageal reflux disease, including management of esophagitis and bleeding complications.This may involve medication management, lifestyle changes, endoscopic procedures, or surgery.
In simple words: This condition, called GERD, occurs when stomach acid comes back up into the esophagus, causing inflammation and bleeding.
This code signifies a chronic digestive disease where stomach acid repeatedly flows back into the esophagus, causing inflammation and bleeding. This inflammation is known as esophagitis.
Example 1: A patient presents with heartburn, difficulty swallowing, and blood in their vomit.Upon endoscopic examination, esophagitis and bleeding are observed, confirming GERD., A patient with a long history of GERD develops worsening symptoms, including chest pain and anemia.Endoscopy reveals active bleeding from inflamed esophageal tissue., A patient with Barrett's esophagus, a complication of GERD, undergoes surveillance endoscopy. The procedure reveals active bleeding within the Barrett's segment.
Symptoms (e.g., heartburn, regurgitation, dysphagia, hematemesis), physical exam findings, endoscopic findings (esophagitis, bleeding), and any relevant diagnostic testing (e.g., biopsy, pH monitoring).
- Specialties:Gastroenterology, internal medicine, family medicine.
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital, Office, Ambulatory Surgical Center,Telehealth Provided in Patient’s Home, Telehealth Provided Other than in Patient’s Home