ICD-10-CM · K21.9
ICD-10 K21.9: Gastro-esophageal reflux disease without esophagitis
GERD diagnosed clinically without endoscopic confirmation of esophagitis.
Code
K21.9
Category
Diseases of the digestive system (K00-K95)
Clinical context
GERD diagnosed clinically without endoscopic confirmation of esophagitis.
Documentation requirements
- Symptom duration ≥2-3 months
- Response to acid suppression therapy
- Distinction from K21.0 (with esophagitis)
Common related procedures
- 43235 EGD (may require PA)
- 99214 E&M
Common payer denial patterns
- EGD denied without documented PPI trial or alarm symptoms
- Long-term PPI (>8 weeks) audit reviews
Frequently asked questions
What does ICD-10 K21.9 mean?
Gastro-esophageal reflux disease without esophagitis
When is this code documented?
GERD diagnosed clinically without endoscopic confirmation of esophagitis.
What documentation supports this code?
Symptom duration ≥2-3 months; Response to acid suppression therapy; Distinction from K21.0 (with esophagitis).
What are common denials associated with this diagnosis?
EGD denied without documented PPI trial or alarm symptoms; Long-term PPI (>8 weeks) audit reviews.
Related diagnoses
Sources
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