ICD-10 GERD – Overview
GERD (Gastroesophageal reflux disease) is a disorder of the digestive system. It is a chronic condition associated with the abnormal functioning of the Lower Esophageal Sphincter (LES) muscle. It is a ring-shaped muscle that is present between the stomach and the esophagus.
The lower esophageal muscle opens the esophagus into the stomach and allows the food to enter the stomach. After the food enters the stomach, it closes and prevents the backflow of food or the stomach’s contents into the esophagus.
ICD-10 Coding Guide for GERD
The ICD-10 coding system (as presented by the World Health Organization) deals with the documentation of diagnosis, treatment, health services, and billing in a healthcare system.
The coding makes it efficient and quicker to bill the services provided to patients in US healthcare. Chapter 11 of the ICD-10 coding guide deals with the diseases of the esophagus, stomach, and duodenum, including Gastroesophageal reflux disease (GERD).
In ICD-10-CM, there are no specific and significant guidelines for GERD. Like other gastrointestinal problems and disorders, GERD is also
usually coded as primary or secondary diagnosis code with endoscopic procedures.
The diagnostic procedures for GERD are Upper gastrointestinal (GI) endoscopy, esophageal pH monitoring, and manometry.
Default ICD-10 Code for GERD:
The default code section in the ICD-10 manual for GERD is K21.
You can use any definitive diagnosis code as primary or secondary in conjunction with the K21 series.
If a definite diagnosis is not present in medical records, you can add other signs and symptoms codes as well with the coding sequencing as:
Primary Dx code: GERD
Secondary Dx code: Signs and symptoms of GERD, e.g., nausea, vomiting.
One diagnosis code you can’t use in conjunction with GERD is P78.83-newborn esophageal reflux.
ICD-10-CM Coding system:
The ICD-10 coding system covers the diagnosis of GERD and other diseases linked to gastroesophageal reflux disease. Following are the ICD-10 codes for GERD and associated conditions:
K21. Gastroesophageal reflux disease (GERD)
K21.0. Gastroesophageal reflux disease with esophagitis
- (Reflux oesophagitis)- chronic acid reflux damages the inner lining of the esophagus.
K21.9. Gastroesophageal reflux disease without esophagitis (esophageal lining remains intact).
- Esophageal reflux NOS
Other GIT ICD-10-CM codes:
Series of codes K20-K31 deal with the diseases of the esophagus, stomach, and duodenum.
K22- Other diseases of the esophagus
K22.1- Ulcers of the esophagus (prolonged exposure to the acid, particularly in chronic GERD, can erode the esophagus and cause ulcers).
K22.2- Esophageal Obstruction (GERD can change the esophageal lining by stricture formation, narrowing the esophagus. Stenosis and constriction of the esophagus can also be the complication of GERD).
K22.3- Perforation of the esophagus (GERD can lead to ulcers and tearing of the esophageal lining. In chronic cases, these ulcers can become perforated and life-threatening). Traumatic rupture of the esophagus is not covered under this section.
K22.4- Dyskinesia of the esophagus (GERD can cause ulceration or stricture in the esophagus. It can cause dyskinesia or dysmotility of the esophagus, which can, in turn, increase the gastroesophageal reflux). It includes the terms Corkscrew Esophagus or Diffused Esophageal Spasm.
K22.5- Diverticulum of the esophagus (GERD can cause weakening of the esophageal diverticula due to acid reflux and a protruding pouch in the esophagus).
K22.6- Gastroesophageal laceration-hemorrhage syndrome ( also termed as Mallory-Weiss syndrome).
K22.7- Barrett’s esophagus/Barret’s Disease/Barret’s syndrome (due to chronic acid exposure, the columnar epithelium replaces the normal squamous cell epithelium of the esophagus- metaplasia of esophagus)
K22.9- Unspecified diseases of the esophagus
K25- Gastric ulcers ( although GERD usually doesn’t cause gastric ulcers, they sometimes coexist with GERD because of their etiology). Increased acidity can cause ulceration along with GERD.
K25.0- Acute Gastric ulcers with hemorrhage
K25.1 Acute Gastric ulcers with perforation
K25.2- Acute Gastric ulcers with bleeding and perforation.
K25.3- Acute Gastric ulcers without hemorrhage or perforation
K25.4- Unspecified chronic gastric ulcers with hemorrhage
K25.5- Unspecified chronic perforated gastric ulcers
K25.6- Unspecified chronic perforated gastric ulcers with hemorrhage
K25.7- Chronic gastric ulcers without hemorrhage and perforation
K25.9- Unspecified gastric ulcers without hemorrhage or perforation
K26- Duodenal ulcers
K26.0- Acute duodenal ulcers with hemorrhage
K26.1- Acute perforated duodenal ulcers
K26.2- Acute perforated duodenal ulcers with hemorrhage
K26.3- Acute duodenal ulcers without hemorrhage and perforation
K26.4- Unspecified chronic duodenal ulcers with hemorrhage
K26.5- Unspecified chronic perforated duodenal ulcers
K26.6- Unspecified chronic perforated duodenal ulcers with hemorrhage
K26.7- Chronic duodenal ulcers without hemorrhage and perforation
K26.9- Unspecified duodenal ulcers without hemorrhage or perforation
K27- Peptic ulcer, site unspecified
K27.0- Acute peptic ulcers with hemorrhage
K27.1- Acute perforated peptic ulcers
K27.2- Acute perforated peptic ulcers with hemorrhage
K27.3- Acute peptic ulcers without perforation or hemorrhage
K27.4- Unspecified chronic peptic ulcers with hemorrhage
K27.5- Unspecified chronic perforated peptic ulcers
K27.6- Unspecified chronic perforated peptic ulcers with hemorrhage
K27.7- Chronic peptic ulcers without hemorrhage and perforation
K27.9- Unspecified peptic ulcers without perforation or hemorrhage
K29- Gastritis and duodenitis (the patterns of gastritis are sometimes associated with GERD due to Helicobacter pylori as one of the causative agents in both diseases).
K29.0- Acute hemorrhagic gastritis
K29.1- Other acute gastritis
K29.5- Unspecified chronic gastritis (Antral chronic gastritis mainly associated with gastroesophageal reflux)
K29.6- Other gastritis
K29.7- Unspecified gastritis
K30- Functional dyspepsia ( GERD occasionally overlaps with functional dyspepsia because of similar symptoms like bloating, heartburn, indigestion, and belching. Sour taste and acid reflex may complicate the process of diagnosis).
K31- Other disorders of the stomach and duodenum
K31.1- Adult hypertrophic pyloric Stenosis (stomach stenosis can be confused with GERD because of the vomiting and backflow of the stomach contents. A thorough physical examination can help diagnose pyloric or stomach stenosis).
Causes of GERD:
GERD is usually associated with a lower esophageal sphincter muscle disorder, but other factors like Hiatal hernias, delayed or impaired esophageal emptying, and stomach emptying also play a role. However, the most common reason for GERD is transient lower esophageal sphincter relaxation (TLESR).
It is a physiological condition, and it is due to weakness or inhibited tone of the lower esophageal sphincter muscle. The muscle relaxes when it shouldn’t, making the stomach’s content backflow.
Risk factors for GERD:
The following things can increase the likelihood of having GERD:
People having Hiatal hernias are more likely to have gastroesophageal reflux disease because of increased reflux of the stomach contents back into the esophagus.
- Gastroparesis (delayed emptying of the stomach)
- Connective tissue diseases (lupus erythematosus, scleroderma, etc.)
- Dietary habits (foods causing acidity, like fried food)
- Inactive or sedentary lifestyle
- Sleeping empty stomach
- Medications (especially those containing aspirin)
Symptoms of GERD:
- Heartburn (the most common symptom)
- Noncardiac chest pain
- Bitter taste behind the mouth in the throat
- Bad breath
- Nausea and vomiting
- Dysphagia (difficulty in swallowing)
- The feeling of fullness or a lump in the throat
- Yellowing of the teeth
- Laryngitis (inflammation of the larynx due to repetitive acid reflux)
- Sleep problems due to an increase in acid reflux during the night (lying aggravates the acid reflux)
- Breathing difficulties ( cough, wheezing, dyspnea) or asthma
GERD and its associated complications :
Gastroesophageal reflux disease is associated with many other complications of the esophagus and stomach. In many cases, GERD causes esophagitis, ulcers of the esophagus, metaplasia of the esophagus (Barret’s esophagus, structure, and constriction of the esophagus), as well as perforation and diverticulitis of the esophagus.
Gastroesophageal reflux disease is also associated with ulceration in the stomach, and it complicates the diagnosis of many other stomach issues because of its general symptoms.
Important coding tips for GERD:
- Code GERD only when no it is confirmed from documents and a definite diagnosis is written.
- When a definitive diagnosis for GERD is not confirmed in medical notes, only code its signs and symptoms.
- If a combination code includes GERD and its signs and symptoms, assign only the combination code instead of using two codes to meet multiple conditions.
- If the facility is Inpatient and the patient is discharged with conditions documented as probable, ruled out, likely, etc. Code only the confirmed or final diagnosis.
- If the facility is, outpatient and discharged condition is probable, questionable, likely, or ruled out. Assign the codes only from signs and symptoms.
Danisa M. Clarrett , MD & Christi ne Hachem, MD; Gastroesophageal Reflux Disease (GERD); Science of Medicine: Feature Series; St. Louis ; 2018.
Kenneth R. DeVault, Donald O. Castell; Updated Guidelines for the Diagnosis and Treatment of Gastroesophageal Reflux Disease; American Journal of Gastroenterology; 2005.
Nayana Ambardekar, MD; GERD; WebMD; 2022.
Nobakht H, Boghratian AH, Sohrabi MR, Panahian M, Rakhshani N, Nikkhah M, Ajdarkosh H, Gholami A , Hemmasi GR, Khonsari MR, Rabiei N, Zamani F; Association between Pattern of Gastritis and Gastroesophageal Reflux Disease in Patients with Helicobacter Pylori Infection; Middle East J Dig Dis 2016;8:206-211.
ICD-10 Version:2019; World Health Organisation.