K21.9 – Gastro-esophageal reflux disease without esophagitis

Billable/ Specific Code:

K21.9 GERD Diagnosis is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.

Applicable to:

• Esophageal reflux NOS

Approximate Synonyms:

• Esophageal reflux finding
• Gastroesophageal reflux
• Gastroesophageal reflux disease
• Gastroesophageal reflux disease co-occurrent and due to diaphragmatic hernia
• Gastroesophageal reflux disease co-occurrent and due to paraesophageal hernia
• Gastroesophageal reflux disease in pregnancy
• Gastroesophageal reflux disease with diaphragmatic hernia
• Gastroesophageal reflux disease with hiatal hernia
• Gastroesophageal reflux disease with paraesophageal hernia
• Gastroesophageal reflux in children
• Gastrointestinal reflux disease in pregnancy
• Gerd (gastro-esophageal reflux disease) (heartburn)
• Laryngitis due to gastroesophageal reflux
• Laryngopharyngeal reflux
• Reflux laryngitis

Clinical Information

• A chronic disorder characterized by reflux of the gastric and/or duodenal contents into the distal esophagus. It is usually caused by incompetence of the lower esophageal sphincter. Symptoms include heartburn and acid indigestion. It may cause injury to the esophageal mucosa.
• A disorder characterized by reflux of the gastric and/or duodenal contents into the distal esophagus. It is chronic in nature and usually caused by incompetence of the lower esophageal sphincter, and may result in injury to the esophageal mucosal. Symptoms include heartburn and acid indigestion.
• Retrograde flow of gastric juice (gastric acid) and/or duodenal contents (bile acids; pancreatic juice) into the distal esophagus, commonly due to incompetence of the lower esophageal sphincter.
• The backward flow of stomach acid contents into the esophagus (the tube that connects the mouth to the stomach).
• Your esophagus is the tube that carries food from your mouth to your stomach. Gastroesophageal reflux disease (gerd) happens when a muscle at the end of your esophagus does not close properly. This allows stomach contents to leak back, or reflux, into the esophagus and irritate it. You may feel a burning in the chest or throat called heartburn. Sometimes, you can taste stomach fluid in the back of the mouth. This is acid indigestion. If you have these symptoms more than twice a week, you may have K21.9 GERD Diagnosis. Anyone, including infants and children, can have gerd. If not treated, it can lead to more serious health problems. In some cases, you might need medicines or surgery. However, many people can improve their symptoms by
  • avoiding alcohol and spicy, fatty or acidic foods that trigger heartburn
  • eating smaller meals
  • not eating close to bedtime
  • losing weight if needed
  • wearing loose-fitting clothes

ICD-10: A Brief Synopsis

For disease reporting, the US utilizes its own national variant of ICD-10 called the ICD-10 Clinical Modification (ICD-10-CM). A procedural classification called ICD-10 Procedure Coding System (ICD-10-PCS) has also been developed for capturing inpatient procedures. The ICD-10-CM and ICD-10-PCS were developed by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS). There are over 70,000 ICD-10-PCS procedure codes and over 69,000 ICD-10-CM diagnosis codes, compared to about 3,800 procedure codes and roughly 14,000 diagnosis codes found in the previous ICD-9-CM.

The expansion of healthcare delivery systems and changes in global health trends prompted a need for codes with improved clinical accuracy and specificity. The alphanumeric coding in ICD-10 is an improvement from ICD-9 which had a limited number of codes and a restrictive structure. Early concerns in the implementation of ICD-10 included the cost and the availability of resources for training healthcare workers and professional coders.

There was much controversy when the transition from the ICD-9-CM to the ICD-10-CM was first announced in the US. Many providers were concerned about the vast number of codes being added, the complexity of the new coding system, and the costs associated with the transition. The Centers for Medicare and Medicaid Services (CMS) weighed these concerns against the benefits of having more accurate data collection, clearer documentation of diagnoses and procedures, and more accurate claims processing. CMS decided the financial and public health cost associated with continuing to use the ICD-9-CM was too high and mandated the switch to ICD-10-CM.