Pediatric Coding Alert

Starting next year, the single code for reflux expands into two separate choices.

Esophageal reflux can occur at all ages, but the condition “is common and often overlooked in children,” according to the Pediatric/Adolescent Gastroesophageal Reflux Association.  If you see this common condition in your practice, get to know how the coding will change next year under ICD-10.

ICD-9 Coding Rules: Under the ICD-9 code set, if you see a pediatric patient and diagnose her with esophageal reflux, you currently report 530.81 (Esophageal reflux) for the visit. 

ICD-10 Changes:  Your coding options will expand to the following two codes effective October 1, 2015, and you’ll select the appropriate code depending on whether the patient has esophagitis or not:

• K21.0 (Gastroesophageal reflux disease with esophagitis)
• K21.9 (Gastroesophageal reflux disease without esophagitis)

Documentation: The determination of whether the patient has esophagitis must be clearly recorded in the patient’s medical record so you can select the appropriate “K” code under ICD-10. “Esophagitis” refers to inflammation or irritation of the esophagus. This can be caused by acid that travels up the esophagus in a patient with reflux.

Coder Tips: You should add both K21.0 and K21.9 to your superbills, with a description of the code so the pediatrician knows which one refers “with esophagitis” and which refers to “without esophagitis.”