Assigning the GERD ICD 10 codes correctly, one has to know about the reflux process, symptoms, tests performed to detect GERD and also GERD ICD 10 guidelines. In this topic, let us learn the above topics along with examples.
Gastro Esophageal Reflux Disease (GERD) is a digestive system disorder in which the stomach acid flows back to esophagus. This can damage the tissue lining of esophagus and makes it difficult to pass food. It is a common digestive system disorder affecting millions of people throughout the world.
Do you wonder why it affects to millions of people? For some people it may be due to old age. But for many others it is due to their obesity, smoking habit, depression, less physical activity, eating more acidity food, not eating on time, some diseases and many other factors.
After we swallow food it goes to esophagus, and the opening called sphincter (valve) opens to allow the food pass into stomach. Then the valve closes. When GERD happens, Sphincter does not close properly and this causes stomach acid and juices flow back to esophagus.
GERD can be mild, moderate, and severe or may even lead to esophageal cancer, if untreated for a long time.
Stomach acid in esophagus can cause any of the below symptoms:
Heartburn – This is the most common symptom. It feels like a burning sensation in the center of the chest.
Regurgitation –You may feel sour taste in mouth because the acid is reaching to mouth or throat. You may even feel some fluid is flowing up and down in stomach and chest.
Dyspepsia –Some patients may also feel stomach discomfort, bloating, burping or nausea.
Chest pain –This symptom can get confused with cardiac chest pain. So, chest pain ICD should be coded if not mentioned as related to reflux.
Physicians use procedures such as upper GI endoscopy, ambulatory acid (pH) probe test, esophageal manometry or upper GI X-ray to detect GERD.
GERD ICD 10 Codes and guidelines:
Location in ICD-10-CM manual – It is located in chapter 11 (Diseases of digestive system) – code range K00 to K95.
It is important to remember the alternate terms used for GERD to find the correct code.
- Laryngopharyngeal reflux
- Acid reflux
- Gastroesophageal Reflux
- Acid backflow
- Gastric reflux
- Cardioesophageal relaxation
GERD ICD 10 Codes Description
K21.00 GERD With esophagitis without bleeding
K21.01 GERD With esophagitis with bleeding
P78.83 Neonatal esophageal reflux
Note: Esophagitis – Inflammation of esophagus
GERD ICD 10 Examples 1
65 year old Jim is seen today with his wife for heartburn more than 6 months. He used to take antacids OTC, but it is not working nowadays. Associated symptoms include dyspepsia. His BMI is 32 kg/m² today. Physician performed abdominal physical exam and documented soft, symmetric, non-tender, without distention. He ordered an upper GI endoscopy abdomen. Biopsy result shows inflammation in the lining of esophagus and acid reflux.
Clinical impression documented as:
- Gastroesophageal Reflux
Here we need to combine both diagnosis and code K21.00. Heartburn and dyspepsia will not be coded as both are symptoms of GERD.
GERD ICD 10 Example 2
40-year-old woman is being evaluated in the clinic for 3 month history of chest pain. This pain occurs often at rest and sometimes at night and lasts for up to two hours. She also gets regurgitation. She denies shortness of breath, wheezing, palpitations, loss of consciousness, or leg swelling. Family history mentioned as non-contributory. Current BP reading is 115/70 mmHg, pulse 74bpm, BMI 30 kg/m². An EKG is performed and results mentioned as normal sinus rhythm. Also, an exercise stress test is performed and that was within normal limits.
Final assessment documented as:
- Chest pain due to above.
ICD code will be K21.9. Chest pain will not be coded here as it is documented as a symptom. If it is not documented as a symptom we would be coding R07.9 as well in the same scenario.
GERD ICD 10 Example 3
Emma, 50 year old female who works in a restaurant, comes to clinic for indigestion from past 3 weeks. She explains that sometimes in the middle of the night she wakes up due to pain in between chest and abdomen and feel a sour taste in mouth. Current BP is 135/75mmHg, pulse 72bpm, BMI 38.2 kg/m².Physical exam documented as obese abdomen. Upper GI X-ray is completed and the result shows gastric reflux.
Diagnoses – (1) Gastric reflux (2) Obesity
Correct coding is K21.9, E66.9, Z68.38