ICD Code K21.9

ICD code K21.9 is used to identify gastro-esophageal reflux disease (GERD) without esophagitis. This code is applied when a patient experiences the backward flow of stomach acid into the esophagus, leading to symptoms such as heartburn or acid regurgitation, but without any inflammation or damage to the esophageal lining. This distinction is important for healthcare providers to accurately document the condition and ensure appropriate treatment and billing.

1. Frequent Heartburn: Persistent burning sensation in the chest, often after eating, which may worsen when lying down or bending over.

2. Regurgitation: Experiencing a sour or bitter-tasting acid backing up into the throat or mouth.

3. Chest Pain: Non-cardiac chest pain that may mimic heart-related issues but is associated with digestive disturbances.

4. Difficulty Swallowing (Dysphagia): Sensation of food being stuck in the throat or chest, or difficulty in swallowing.

5. Chronic Cough: A persistent cough that is not related to respiratory infections or other known causes.

6. Hoarseness or Sore Throat: Chronic sore throat or hoarseness, especially in the morning, due to acid irritation.

7. Nausea: Frequent episodes of nausea without an apparent cause.

8. Laryngitis: Inflammation of the larynx leading to voice changes, often due to acid irritation.

9. Asthma-like Symptoms: Worsening of asthma symptoms or development of asthma-like symptoms due to acid reflux.

10. Dental Erosion: Unexplained dental erosion due to acid exposure.

These criteria should be evaluated by a healthcare provider to determine the appropriate use of the ICD code for diagnosis and treatment planning.

For the ICD code K21.9, which pertains to gastro-esophageal reflux disease without esophagitis, the relevant CPT codes that may be used for treatment and management 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. 91035 - Esophagogastric reflux test; with nasal catheter pH electrode(s) placement, recording, analysis and interpretation.

4. 91034 - Esophageal motility (manometric) study, each additional 15 minutes of recording (List separately in addition to code for primary procedure).

5. 91010 - Esophageal motility (manometric) study, with interpretation and report.

These CPT codes are commonly associated with the diagnostic and procedural approaches to managing conditions related to gastro-esophageal reflux disease without esophagitis. It's important for healthcare providers to select the appropriate CPT code based on the specific services rendered during patient care.

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