ICD 10 Coding Alert

Reader Question:

Know the Signs, Code This GERD Scenario

Question: A patient presented to our ED because of burning throat pain and denied chest pain. The physician determined that the patient had heartburn caused by GERD. Which diagnoses codes should we report for the final diagnosis, as well as the signs and symptoms, and which procedure code should we submit?

Arkansas Subscriber

Answer: If your provider identifies GERD, you will need to assign one of the two ICD-10 codes assigned to this condition. In this scenario, as the provider confirmed a diagnosis of GERD, you would typically code it as K21.9 (Gastro-esophageal reflux disease without esophagitis).

Signs and symptoms: If patient has heartburn and indigestion but GERD has not been specifically diagnosed, then the signs and symptoms would be coded. For example:

  • R12 - Heartburn
  • R05 - Cough
  • K30 - Functional dyspepsia
  • R06.2 - Wheezing
  • J37.0 - Chronic laryngitis
  • J37.1 - Chronic laryngotracheitis.

Don't forget: Remember to report the most appropriate E/M code (99281-99285) for the ED visit.