GERD ICD-10 CM coding Guide for Coders

Basics of GERD ICD-10 CM code

Gastroesophageal reflux disease (GERD) is a chronic digestive disease, which happens when a muscle at the end of the esophagus does not close. It occurs when the stomach content flows back into the food pipe(esophagus). This reverse flow causes reflux, that irritates the lining of your esophagus and hence causes GERD. Upper GI (gastrointestinal) procedures (74240-74250) are the common procedures performed in when the patient comes with symptoms of GERD diagnosis. GERD ICD 10 code, K21.9, is the most commonly coded  primary diagnosis for these procedures. We will learn more about the sign and symptoms for ICD 10 code for GERD.

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Symptoms for diagnosis code for GERD

The most common symptom, which I have come across while coding is heartburn (R12) or dysphagia (R13.10).We have main other sign and symptoms for GERD ICD 10 codes which you find it below.

Sign and Symptoms for GERD

• frequent heartburn
• chest pain
• regurgitation of partially digested food into the back of your throat
• trouble swallowing (dysphagia)
• coughing
• sore throat
• hoarseness

Commonly procedures performed for GERD

Barium Swallow (74220)

Modified Barium Swallow (74230)

Upper GI series (74240-74250)

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IC9 and ICD 10 code for GERD

In ICD 9 we have used 530.81, for coding GERD. Now, with the use of ICD 10 codes we have to use K21.9, as ICD 10 code for GERD. Hence, be careful if you are following ICD 10 coding guidelines, do use K21.9 code for gastroesophageal reflux (GERD). Below are some the similar ICD 10 codes for GERD, which you can come across. ICD-10 is required for use by physicians and healthcare providers under the Health Insurance Portability & Accountability Act (HIPAA).

    K21.0- Gastro-esophageal reflux disease with esophagitis.

    K21.9 -Gastro-esophageal reflux disease without esophagitis.

Esophageal reflux indicates incompetence of the lower esophageal sphincter and characterized by regurgitation of the gastric contents into the esophagus.

Esophagitis refers to an inflammation of the esophagus. Esophagitis is an inflammation of the lining of the esophagus and can be caused by an infection or irritation. Gastroesophageal reflux disease (GERD) occurs when stomach acid flows back into the esophagus and may also cause esophagitis. Other causes include, but are not limited to infection, medication, and allergies. If untreated, esophagitis can lead to bleeding, ulceration, and chronic scarring. These new codes were created to reflect the presence of bleeding.

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Synonyms for  GERD

• Gastroesophageal reflux disease
• Gastroesophageal reflux in child
• Gastroesophageal reflux in children
• GERD (gastroesophageal reflux disease)
• GERD (gastro-esophageal reflux disease) (heartburn)
• Laryngitis due to gastroesophageal reflux
• Reflux laryngitis

Supporting CPT code for diagnosis Gastroesophageal reflux disease (GERD)