Gastroesophageal reflux disease without esophagitis icd 10

Coding GERD (Gastroesophageal reflux disease) in ICD-10-CM

Overview 
Gastroesophageal reflux disease (GERD) is the most common disease encountered by the gastroenterologist. It is a chronic disease. This happens when the muscle at the end of the esophagus does not close. Anyone can have GERD, even infants and children. GERD can be with or without heart burn. The following guideline will provide an overview of GERD and its presentation, management of this common and important disease and comparison between ICD9 and ICD 10 Coding pattern.

Symptoms
Everyone has experienced gastroesophageal reflux. It happens when you burp, have an acid taste in your mouth or have heartburn. However, when these symptoms interfere in the daily activities it is a matter of concern

Other symptoms that occur less frequently, but can indicate GERD are:

• Acid regurgitation (retasting your food after eating)
• Difficulty or pain when swallowing
• Sudden excess of saliva
• Chronic sore throat
• Laryngitis or hoarseness
• Inflammation of the gums
• Cavities
• Bad breath
• Chest pain

Conditions that increase GERD include:

• Obesity
• Smoking
• Dry mouth
• Diabetes
• Asthma
• Delayed gastric emptying

 Diagnosis : Several tests may be used to diagnose GERD including :
X-ray of the upper digestive system

• Endoscopy (examines the inside of the esophagus)
• Ambulatory acid (pH) test (monitors the amount of acid in the esophagus)
• Esophageal impedance test (measures the movement of substances in the esophagus)

Complications :

• Esophageal stricture
• Esophageal ulcer
• Barretts’ esophagus.

Treatment & Management :
If GERD and asthma both are present then, managing  GERD helps in  controlling  asthma symptoms.
Lifestyle changes that can help in improving the symptoms are:

• Elevating the head of the bed 6-8 inches.
• Losing weight.
• Stopping  smoking.
• Decreasing alcohol intake.
• Eating smaller meals and avoiding heavy evening meals.
• Not lying down within two to three hours of eating.

Coding Guidelines for Coding GERD In ICD 10:

The coding guidelines for the common digestive system disease GERD  is as follows :
In ICD-9-CM , 530.81 is the code for GERD.
In ICD-10-CM, there are two codes , but it doesn’t include the abbreviation GERD. The codes are:

• K21.0, gastro-esophageal reflux disease with esophagitis.
• K21.9, gastro-esophageal reflux disease without esophagitis.

The only difference in ICD-10-CM is that the physician must document whether the patient has esophagitis, defined as – any inflammation, irritation, or swelling of the esophagus. When esophagitis is not documented, a query to the physician should be made for clarification purposes.

HCPRO