Diseases of the Digestive System
ICD-10 Code: K21.9
Gastro-Esophageal Reflux Disease Without Esophagitis
GERD with acid reflux symptoms but no esophageal inflammation on endoscopy.
Clinical Information
GERD with acid reflux symptoms but no esophageal inflammation on endoscopy. Common in US healthcare settings with specific coding requirements per ICD-10-CM guidelines.
Coding Guidelines
- 1Use K21.9 when clinical documentation supports this diagnosis
- 2Verify specificity requirements per ICD-10-CM Official Guidelines
- 3Code to highest level of specificity documented
- 4Consider associated conditions and combination coding rules
Common Uses
- Primary diagnosis in ambulatory settings
- Secondary diagnosis in inpatient settings
- ED/urgent care encounters
- Follow-up and monitoring visits
Related ICD-10 Codes
K21.XRelated code in same category
See ICD-10-CM manualFor complete related code list
Documentation Requirements
- Physician documentation must clearly state diagnosis
- Include severity, laterality, and specificity when applicable
- Document underlying cause if known
- Note acute vs. chronic where relevant
Real-World Coding Examples
Patient presents with gastro-esophageal reflux disease without esophagitis. Clinical findings support K21.9 diagnosis.
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