Coding for Gastroesophageal Reflux Disease (GERD) A common digestive disorder, gastroesophageal reflux disease (GERD), also referred to as acid regurgitation, occurs when the stomach acid refluxes into the esophagus. The condition can cause a burning sensation (known as heartburn) in the chest. If left untreated, this gastroenterology condition can lead to serious complications such as narrowing of the esophagus, esophageal ulcer and precancerous changes to the esophageal structure (known as Barrett’s esophagus). Documenting this condition requires correct recording of all the symptoms and treatments provided. Partneirng with a gastroenterology medical coding company can help physicians ensure accurate and timely claim submission and appropriate reimbursement. GERD is common in people of all age groups. The condition is more commonly seen in people who are obese or overweight, pregnant women, active or secondhand smokers and people who consume certain antidepressant medications. Heartburn or a burning sensation in the chest, usually after eating is one of the most common symptoms of this condition. Other symptoms include chest pain, regurgitation of food or sour liquid, difficulty swallowing, nausea or vomiting, and a sensation of a lump in your throat. Medical Codes for GERD Diagnosis of this condition involves a medical history, physical exam and identification of the causes and symptoms. Tests such as Upper gastrointestinal (GI) endoscopy, Esophageal manometry, Ambulatory acid (pH) probe test and Upper GI series X-ray are used to diagnose the condition. Understanding the disease, its diagnostic process, and the definitions of key terms in the code description helps coders identify crucial details in the documentation, ensuring accurate assignment of the appropriate ICD-10 code. ICD-10 Codes • • • • •
K21 Gastro-esophageal reflux disease K21.0 Gastro-esophageal reflux disease with esophagitis K21.00 …… without bleeding K21.01 …… with bleeding K21.9 Gastro-esophageal reflux disease without esophagitis
GERD without esophagitis or bleeding represents the least severe stage of the disease and is reported with K21.9. If the medical record does not indicate esophagitis (inflammation or irritation of the esophagus) or bleeding, K21.9 should be assigned. www.outsourcestrategies.com
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CPT Codes • 43200 – Esophagoscopy, diagnostic • 43201 – Esophagoscopy flexible, transoral; with directed submucosal injection(s), any substance • 43210 – Esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed • 43236 – Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance • 43241 – Esophagogastroduodenoscopy, flexible, transoral; with insertion of intraluminal tube or catheter • 43257 – Esophagogastroduodenoscopy, flexible, transoral; with delivery of thermal energy to the muscle of lower esophageal sphincter and/or gastric cardia, for treatment of gastroesophageal reflux disease • 43284 – Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e., magnetic band), including cruroplasty when performed • 43289 Unlisted laparoscopy procedure, esophagus • 43499 Unlisted procedure, esophagus • 43999 Unlisted procedure, stomach GERD can be the underlying cause of various conditions, including Barrett’s esophagitis. This condition occurs when the normal esophageal lining is replaced by abnormal cells, typically due to prolonged acid reflux from GERD. If left unmonitored, these abnormal cells, combined with chronic GERD, can progress to dysplasia or even esophageal cancer, necessitating more aggressive treatment. Gastroenterology medical billing and coding can be challenging due to the wide range of diagnostic and procedural codes, frequent updates to coding guidelines, and the need for precise documentation to support medical necessity. Conditions like GERD, Barrett’s esophagus, and inflammatory bowel diseases require accurate ICD-10-CM and CPT code selection to ensure proper reimbursement while avoiding claim denials. Billing for endoscopic procedures, screenings, and treatments also comes with specific coding rules. Outsourcing medical billing and coding can ensure the expertise essential for compliance and revenue optimization.
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