2025 ICD-10-CM code K21.9
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Diseases of the digestive system - Gastro-esophageal reflux disease Diseases of the digestive system (K00-K95) Feed
Gastroesophageal reflux disease (GERD) without esophagitis.
The medical necessity for coding K21.9 is established by the presence of GERD symptoms documented in the medical record and confirmed by the absence of esophagitis on examination or testing. The symptoms should be clinically significant enough to warrant diagnosis and treatment.
Diagnosis and management of GERD.This may include ordering tests to rule out esophagitis, recommending lifestyle changes (diet, weight loss), and prescribing medications (antacids, proton pump inhibitors).
In simple words: This code means a person has heartburn or acid reflux, but their esophagus isn't inflamed or damaged.
K21.9 is a billable ICD-10-CM code that represents gastroesophageal reflux disease (GERD) without evidence of esophagitis.GERD is a condition where stomach acid flows back into the esophagus.This code specifically applies when there is no inflammation or erosion of the esophageal lining (esophagitis).
Example 1: A 45-year-old patient presents with chronic heartburn and regurgitation.Endoscopy reveals no esophagitis.K21.9 is coded., A 60-year-old patient reports intermittent heartburn after large meals.Upper endoscopy is normal. K21.9 is coded., A 30-year-old patient with a history of GERD symptoms undergoes endoscopy which shows no evidence of esophageal inflammation or injury. K21.9 is coded.
Provider documentation should clearly state a diagnosis of GERD and specifically note the absence of esophagitis.Findings from relevant investigations (e.g., endoscopy) should support the diagnosis.
** K21.9 is used when the patient has GERD symptoms but no evidence of esophagitis.The absence of esophagitis is crucial for accurate coding. Always review the complete clinical picture to ensure appropriate code selection.
- Payment Status: Active
- Specialties:Gastroenterology
- Place of Service:Office, Hospital Inpatient, Hospital Outpatient, Ambulatory Surgical Center