Gastroenterology Coding Alert

Question: Which diagnosis code should I use to report reflux laryngopharyngitis?

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Answer: This is a challenging diagnosis to report because there are technically two diagnoses at play — laryngopharyngeal reflux and laryngopharyngitis. According to Stedman’s Medical Dictionary, laryngopharyngeal reflux is “a form of gastroesophageal reflux disease that produces prominent symptoms and signs in the pharynx and larynx characterized by acute, chronic, and intermittent laryngitis and pharyngitis.”

Fortunately,  Stedman’s makes the coding process infinitely easier by laying out which condition is a symptom of the other. Since the laryngopharyngitis is a symptom of the laryngopharyngeal reflux, you know that you should report the laryngopharyngeal reflux as the primary diagnosis. The ICD-10-CM index does not offer the option of coding this diagnosis specifically, so you will have to resort to coding K21.9 (Gastro-esophageal reflux disease without esophagitis).

You’ve now got to make a consideration as to whether you should separately report the laryngopharyngitis as a secondary diagnosis. As a general rule, coding common symptoms of your underlying diagnosis is not necessary and often considered redundant. In this case, Stedman’s clearly lays out that laryngitis and pharyngitis are common symptoms of laryngopharyngeal reflux. Therefore, it is not appropriate to separately report these conditions alongside K21.9.