K21.9
Gastro-esophageal reflux disease without esophagitis
Diseases of the digestive system Billable
Quick Reference
Chronic heartburn or acid reflux without endoscopic evidence of esophagitis
Clinical Information
When to Use This Code
Chronic heartburn or acid reflux without endoscopic evidence of esophagitis
Common Clinical Scenarios
- GERD on PPI therapy
- Chronic heartburn management
- Reflux symptoms responsive to acid suppression
- Lifestyle modifications for GERD
Documentation Requirements
- Document symptoms: heartburn, regurgitation, dysphagia
- Note PPI or H2 blocker therapy
- Record endoscopy results if performed (showing no esophagitis)
- Document frequency and severity of symptoms
Coding Guidelines
Inclusion Terms
These terms are included in this code:
GERDGastroesophageal refluxAcid refluxHeartburn
Exclusion Terms
Do NOT use this code for:
- GERD with esophagitis (K21.0)
- Esophageal ulcer (K22.1-)
Coding Notes
Use K21.0 when esophagitis documented on endoscopy
Do not use for simple heartburn without chronic pattern
Code Barrett's esophagus separately (K22.7-)
Related ICD-10 Codes
Consider these related codes based on patient presentation:
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Code
K21.9
Category
Diseases of the digestive system
Billable Status
Billable
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