Gastroenterology Coding Alert

Find out how to report testing procedures for GERD.

Gastroesophageal reflux disease (GERD) is considered a digestive disorder that affects the lower esophageal sphincter. Diagnosing the disease isn’t an open-and-shut process, and sometimes gastroenterology coders may need to hold off on assigning a GERD code for the patient’s condition.

Revenue Cycle Insider has broken down this condition and how to code the testing procedures and diagnoses. Read on to learn more about coding GERD encounters.

Get to Know GERD

The lower esophageal sphincter, when performing normally, opens and closes for food to get to the stomach. When the esophageal sphincter is weakened or too relaxed, it may open when it shouldn’t, allowing stomach acid to back up. GERD can occur in a patient, at any age, sometimes for an unknown reason.

The stomach has a lining that protects it from the acid, but the esophagus doesn’t have a protective lining and, therefore, is susceptible to pain and irritation from the acid backing up. In some cases, the acid backup is temporary and resolves on its own. In other cases, if more severe, GERD can become a chronic issue that must be treated with medication or surgery. Reflux can affect more than just the esophagus. GERD can also cause inflammation in the pharynx and the larynx, which can lead to bronchitis, asthma, or pneumonia.

Code Different GERD Diagnoses

GERD is broken down into two different types, GERD with or without esophagitis. Esophagitis means that there is visible inflammation or damage to the esophagus. Accurate coding of GERD matters as it ensures better tracking of patient outcomes, helps determine appropriate treatments, ensures clean claim submissions, and helps with monitoring of national trends. The code category for GERD in the ICD-10-CM book is K21.- (Gastroesophageal reflux disease); two of the codes beneath K21.- are:

• K21.0- (Gastro-esophageal reflux disease with esophagitis)
• K21.9 (Gastro-esophageal reflux disease without esophagitis)

You’ll use a K21.0- code when the provider documented esophageal inflammation. These codes are typically for more severe cases of GERD. The K21.0- codes differ in whether the patient is also experiencing bleeding with the inflammation. Assign K21.00 (Gastro-esophageal reflux disease with esophagitis, without bleeding) if the physician notes no bleeding is present. On the other hand, use K21.01 (Gastro-esophageal reflux disease with esophagitis, with bleeding) when the provider documents the presence of bleeding.

Assign code K21.9 when a more specified type is not documented. Usually, this code reflects mild or early-stage GERD.

Of course, you might receive reports where the gastroenterologist hasn’t made a definitive GERD diagnosis yet because more testing is needed. In those cases, you’ll need to report signs or symptoms that the patient presents with or another code that could be related to the disease.

For example, you’ll assign R12 (Heartburn) only when GERD is not already diagnosed. Use R53.1 (Weakness) if the provider determines the patient is fatigued due to sleep issues related to GERD symptoms.

If the patient’s GERD has been documented as resolved and they are attending follow-up visits, you’ll assign Z87.19 (Personal history of other diseases of the digestive system) to reflect the patient’s history of the disease.

Recognize Common GERD Diagnostic Procedures

A gastroenterologist or other healthcare provider can order any of the following procedures for patients that have atypical symptoms, patients experiencing more severe symptoms, patients for whom other treatments haven’t worked, or when anti-reflux surgery is considered:

• Upper endoscopy (diagnostic): Upper endoscopy is best for evaluating reflux-induced esophageal injury and diagnosing esophagitis and Barrett’s esophagus.

1762. 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed)

• Reflux testing (wireless pH/pH impedance): Reflux testing can be performed by wireless pH testing or 24-hour pH impedance. Wireless testing allows for a 48-hour evaluation of the reflux activity while the patient continues normal activities. In pH impedance testing, the testing measures the pH level (level of acidity). A catheter is placed in the nose and used to spot the flow of liquid from the stomach into the esophagus.

1762. 91034 (Esophagus, gastroesophageal reflux test; with nasal catheter pH electrode(s) placement, recording, analysis and interpretation) and 91035 (… with mucosal attached telemetry pH electrode placement, recording, analysis and interpretation)

• Esophageal manometry: This treatment cannot diagnose GERD, but it can rule out other conditions that mimic the symptoms of the disease. It is used to determine if impedance testing is needed. The catheter evaluates the muscle contractions and tests the strength and relaxation function in the lower esophageal sphincter.

1762. 91010 (Esophageal motility (manometric study of the esophagus and/or gastroesophageal junction) study with interpretation and report) and +91013 (… with stimulation or perfusion (eg, stimulant, acid or alkali perfusion) (List separately in addition to code for primary procedure))

• Barium esophagram: This is a very commonly used X-ray study. The patient swallows a contrast solution, and the contrast coats the esophagus and gastrointestinal tract, allowing the provider to detect any abnormalities. It can also be used to evaluate an injury to the esophagus.

1762. 74220 (Radiologic examination, esophagus, including scout chest radiograph(s) and delayed image(s), when performed; single-contrast (eg, barium) study) and 74221 (… double-contrast (eg, high-density barium and effervescent agent) study)

Grasp GERD Treatment Options

In the early stages of GERD, providers can recommend lifestyle changes to improve or treat the condition. Lifestyle changes include losing weight and avoiding certain foods that increase the level of acid in the stomach, such as caffeinated beverages. Physicians may also suggest laying off food that decreases the pressure in the lower stomach, like fatty foods, alcohol, or peppermint. Steering clear of large meals, quitting smoking, not lying down right after a meal, and elevating the head when lying down may also be recommended to patients.

When lifestyle changes do not take care of the issues related to GERD, medications are available that physicians can prescribe. Some of the most common medications include antacids, histamine blockers, proton pump inhibitors (PPI), and prokinetic agents.

Transoral incisionless fundoplication (TIF) therapy is another treatment option to address GERD. TIF allows a shorter recovery time than other laparoscopic procedures available. In one example of TIF therapy, the provider creates sutures in the stomach to increase the anti-reflux barrier.

In some cases, when all previous options have not relieved the GERD, surgery might be the most appropriate option. During a Nissen fundoplication, the physician wraps the upper part of the stomach around the lower part of the esophagus to create a barrier that can allow for permanent relief from GERD. LINX surgery involves a string of magnetic beads that is wrapped around the lower esophageal sphincter to compress and strengthen it. The Stretta procedure is a nonsurgical procedure where the surgeon inserts an endoscope and uses radiofrequency energy to create tiny cuts in the esophageal tissue. As the cuts heal, scar tissue is formed that strengthens the esophageal tissue and helps to block the nerves that respond to the acid reflux.

Cristin Robinson, CPC, CPMA, CCC, CRC, CEMC, AAPC Approved Instructor,
Education Coding Consultant, Bristol, Tennessee