ICD Code K21.00

ICD code K21.00 is used to identify gastro-esophageal reflux disease (GERD) with esophagitis, which is an inflammation of the esophagus, but without any associated bleeding. This code is utilized by healthcare providers to accurately document and bill for cases where a patient experiences acid reflux that has led to esophageal irritation, yet does not involve any bleeding complications.

1. Presence of Gastroesophageal Reflux Symptoms: The patient exhibits symptoms such as heartburn, regurgitation, or acid taste in the mouth, which are indicative of gastroesophageal reflux.

2. Esophagitis Confirmation: Diagnostic tests, such as an endoscopy, confirm the presence of esophagitis, which is inflammation of the esophagus lining.

3. Absence of Bleeding: There is no evidence of bleeding in the esophagus, as confirmed by clinical evaluation or diagnostic testing.

4. Chronic or Recurrent Symptoms: The symptoms are persistent or recurrent, suggesting a chronic condition rather than an isolated incident.

5. Response to Treatment: The patient may have a history of partial or temporary relief from symptoms with the use of antacids, proton pump inhibitors, or H2 blockers, indicating a reflux-related issue.

6. Exclusion of Other Conditions: Other potential causes of esophagitis, such as infections, medications, or autoimmune disorders, have been ruled out through appropriate testing and clinical evaluation.

7. Patient History: The patient's medical history supports a diagnosis of gastroesophageal reflux disease, with documented episodes of reflux symptoms and esophagitis.

8. Lifestyle Factors: Consideration of lifestyle factors that may contribute to reflux, such as diet, obesity, smoking, or alcohol consumption, which align with the diagnosis.

9. Diagnostic Imaging: Imaging studies, if performed, do not show any structural abnormalities that could explain the symptoms, supporting a diagnosis of reflux-related esophagitis.

10. Symptom Correlation: There is a clear correlation between the patient's symptoms and the presence of esophagitis, without any signs of bleeding, aligning with the diagnostic criteria for this condition.

For the ICD code K21.00, which pertains to gastro-esophageal reflux disease with esophagitis, without bleeding, the relevant CPT codes that may be applicable for treatment include:

1. 43235 - Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure).

2. 43239 - Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple.

3. 43249 - Esophagogastroduodenoscopy, flexible, transoral; with balloon dilation of esophagus (less than 30 mm diameter).

4. 43248 - Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by dilation of esophagus over guide wire.

5. 91035 - Esophageal pH monitoring, with or without impedance, catheter-based for 24 hours.

These CPT codes are commonly used for diagnostic and therapeutic procedures related to the management of gastro-esophageal reflux disease with esophagitis. It is important for healthcare providers to select the appropriate CPT code based on the specific procedures performed and the clinical scenario.

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