Gastroesophageal reflux disease unspecified whether esophagitis present

Code

K21.9 - Gastro-esophageal reflux disease without esophagitis
[Billable]

Includes

  • Esophageal reflux NOS

Code Tree

K00-K95 - Diseases of the digestive system

  • K20-K31 - Diseases of esophagus, stomach and duodenum
    • K21 - Gastro-esophageal reflux disease
      • K21.0 - Gastro-esophageal reflux disease with esophagitis
      • K21.9 - Gastro-esophageal reflux disease without esophagitis

K21.9 - Gastro-esophageal reflux disease without esophagitis is a sample topic from the ICD-10-CM.

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ICD-10-CM 2023 Coding Guideā„¢ from Unbound Medicine. Search online 72,000+ ICD-10 codes by number, disease, injury, drug, or keyword. Complete Product Information.

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Hi what is the Primary DX you are using ? Some plans in some states do not consider B96.81 by itself or as Primary, a valid DX for CPT 78267, 78268. You can try using A04.8 or R10.13 or K21.9 along wi... [ Read More ]

[QUOTE="magalifano, post: 505367, member: 529169"] This is just billing for anesthesia for procedure of endoscopy . k21.9, k22.70,k29.70. CPT 00731. CRNA performs the anesthesia. Modifier QZ and with... [ Read More ]

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Overview

Gastroesophageal reflux disease (GERD) occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of your esophagus.

Many people experience acid reflux from time to time. However, when acid reflux happens repeatedly over time, it can cause GERD.

Most people are able to manage the discomfort of GERD with lifestyle changes and medications. And though it's uncommon, some may need surgery to ease symptoms.

Symptoms

Common signs and symptoms of GERD include:

  • A burning sensation in your chest (heartburn), usually after eating, which might be worse at night or while lying down
  • Backwash (regurgitation) of food or sour liquid
  • Upper abdominal or chest pain
  • Trouble swallowing (dysphagia)
  • Sensation of a lump in your throat

If you have nighttime acid reflux, you might also experience:

  • An ongoing cough
  • Inflammation of the vocal cords (laryngitis)
  • New or worsening asthma

When to see a doctor

Seek immediate medical care if you have chest pain, especially if you also have shortness of breath, or jaw or arm pain. These may be signs and symptoms of a heart attack.

Make an appointment with your doctor if you:

  • Experience severe or frequent GERD symptoms
  • Take over-the-counter medications for heartburn more than twice a week

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Causes

GERD is caused by frequent acid reflux or reflux of nonacidic content from the stomach.

When you swallow, a circular band of muscle around the bottom of your esophagus (lower esophageal sphincter) relaxes to allow food and liquid to flow into your stomach. Then the sphincter closes again.

If the sphincter does not relax as it should or it weakens, stomach acid can flow back into your esophagus. This constant backwash of acid irritates the lining of your esophagus, often causing it to become inflamed.

Risk factors

Conditions that can increase your risk of GERD include:

  • Obesity
  • Bulging of the top of the stomach up above the diaphragm (hiatal hernia)
  • Pregnancy
  • Connective tissue disorders, such as scleroderma
  • Delayed stomach emptying

Factors that can aggravate acid reflux include:

  • Smoking
  • Eating large meals or eating late at night
  • Eating certain foods (triggers) such as fatty or fried foods
  • Drinking certain beverages, such as alcohol or coffee
  • Taking certain medications, such as aspirin

Complications

Over time, chronic inflammation in your esophagus can cause:

  • Inflammation of the tissue in the esophagus (esophagitis). Stomach acid can break down tissue in the esophagus, causing inflammation, bleeding, and sometimes an open sore (ulcer). Esophagitis can cause pain and make swallowing difficult.
  • Narrowing of the esophagus (esophageal stricture). Damage to the lower esophagus from stomach acid causes scar tissue to form. The scar tissue narrows the food pathway, leading to problems with swallowing.
  • Precancerous changes to the esophagus (Barrett esophagus). Damage from acid can cause changes in the tissue lining the lower esophagus. These changes are associated with an increased risk of esophageal cancer.

Gastroesophageal reflux disease (GERD) care at Mayo Clinic

July 26, 2022

  1. Maret-Ouda J, et al. Gastroesophageal reflux disease: A review. JAMA. 2020; doi:10.1001/jama.2020.21360.
  2. Katz PO, et al. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease. American Journal of Gastroenterology. 2022; doi:10.14309/ajg.0000000000001538.
  3. Acid reflux (GER and GERD) in adults. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/acid-reflux-ger-gerd-adults. Accessed April 13, 2022.
  4. Kahrilas PJ. Clinical manifestations and diagnosis of gastroesophageal reflux in adults. https://www.uptodate.com/contents/search. Accessed April 13, 2022.
  5. AskMayoExpert. Gastroesophageal reflux disease (GERD) (adult). Mayo Clinic. 2021.
  6. Townsend CM Jr, et al. Gastroesophageal reflux disease and hiatal hernia. In: Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 21st ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed April 13, 2022.
  7. Feldman M, et al., eds. Gastroesophageal reflux disease. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 11th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed April 13, 2022.
  8. Kahrilas PJ. Medical management of gastroesophageal reflux in adults. https://www.uptodate.com/contents/search. Accessed April 13, 2022.
  9. Winter HS. Management of gastroesophageal reflux disease in children and adolescents. https://www.uptodate.com/contents/search. Accessed April 13, 2022.
  10. Ami TR. Allscripts EPSi. Mayo Clinic. April 7, 2022.
  11. Khanna S (expert opinion). Mayo Clinic. May 1, 2022.

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What does gastroesophageal reflux disease without esophagitis mean?

It's possible to have GERD without esophagitis, or inflammation of the esophagus. This is often related to PPI therapy, which lowers the acidity of reflux. However, because PPIs don't control the reflux itself, symptoms such as regurgitation may persist. In this case, you'll need treatment to control the reflux.

What is esophagitis present?

Esophagitis (uh-sof-uh-JIE-tis) is inflammation that may damage tissues of the esophagus, the muscular tube that delivers food from your mouth to your stomach. Esophagitis can cause painful, difficult swallowing and chest pain.

How do you treat gastroesophageal reflux disease?

Lifestyle and home remedies.
Maintain a healthy weight. ... .
Stop smoking. ... .
Elevate the head of your bed. ... .
Start on your left side. ... .
Don't lie down after a meal. ... .
Eat food slowly and chew thoroughly. ... .
Avoid foods and drinks that trigger reflux. ... .
Avoid tight-fitting clothing..

Can esophagitis be life threatening?

Esophagitis can have serious consequences that affect your quality of life. If left untreated, esophagitis may develop into a condition called Barrett's esophagus. This may increase your risk for esophageal cancer.