Primary Care Coding Alert

Question: Our provider established that one of our patients suffers from gastro-esophageal reflux disease (GERD) and prescribed medication. Which diagnosis code do I use? The notes say nothing about whether the patient has esophagitis, so I’m hesitant to report K21.9.

Illinois Subscriber

Answer: Whether the patient has esophagitis is useful information, however you can still confidently assign K21.9 (Gastro-esophageal reflux disease without esophagitis). The reason why can be found under the descriptor in ICD-10. “Esophageal reflux NOS” is written underneath the entry for K21.9, which accounts for these types of circumstances.

Note: Classic symptoms of GERD can also be caused by cardiac or pulmonary problems, so be sure to report any pre-existing chronic conditions and habits that may exacerbate GERD, such as J45.- (Asthma), E66.- (Overweight and obesity), or Z72.0 (Tobacco use), following the applicable coding guidelines.