GERD ICD-10 codes
Start with the primary code, then move to a more specific related code when the documentation supports it.
K21.9 | Gastro-esophageal reflux disease without esophagitis | ICD-10-CM |
K21.00 | GERD with esophagitis, without bleeding | ICD-10-CM |
K21.01 | GERD with esophagitis, with bleeding | ICD-10-CM |
R12 | Heartburn | ICD-10-CM |
K22.70 | Barrett's esophagus without dysplasia | ICD-10-CM |
Use K21.9 for GERD without esophagitis. Use K21.00 or K21.01 when esophagitis is documented, depending on bleeding. Use R12 for heartburn when GERD is not diagnosed.
“Three months of post-prandial burning and regurgitation, worse lying down. No dysphagia, weight loss, hematemesis, or melena. Assessment: gastro-esophageal reflux disease without alarm features; PPI trial started.”
Paste a note or record audio. Notat’s FactsContext™ engine extracts the raw clinical facts first, then suggests codes from that context so you can inspect the evidence before using anything.
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3
I10ICD-10-CM
Essential (primary) hypertension
Belägg: “Chief Complaint Elevated and fluctuating blood pressure readings.”
E78.5ICD-10-CM
Hyperlipidemia, unspecified
Belägg: “2. Hyperlipidemia. Clinically stable on atorvastatin.”
M19.90ICD-10-CM
Unspecified osteoarthritis, unspecified site
Belägg: “3. Osteoarthritis. Symptoms stable. Continue conservative management with acetaminophen as needed.”
FactsContext extracts clinical facts first: diagnoses, symptoms, negatives, findings, test results, medications, and plan decisions.
The clinician can read and reuse the extracted medical context directly, independent of the generated note.
AI suggestions are not a substitute for clinician judgment, payer rules, local coding policy, or the official code set.
FAQ
When do I use K21.00?
Use K21.00 when GERD with esophagitis is documented and there is no bleeding.
Can I code heartburn as GERD?
Only if the clinician diagnoses GERD. Otherwise heartburn alone is coded R12.
Can AI separate symptom and diagnosis?
Notat extracts symptoms, alarm features, endoscopy findings, and assessment as clinical facts, so the suggested code follows the documented diagnosis rather than a guess.