Gastro-esophageal reflux dis with esophagitis, without bleed

This code signifies gastro-esophageal reflux disease (GERD) where the reflux of stomach acid into the esophagus has caused inflammation (esophagitis). Importantly, there is no evidence of active bleeding associated with this esophagitis. It represents a common chronic digestive disorder characterized by symptoms like heartburn and regurgitation, with documented esophageal mucosal injury.

Use this code when the physician's documentation clearly states a diagnosis of GERD with esophagitis, and specifically notes the absence of bleeding. This typically applies to patients presenting with symptoms of GERD who have undergone endoscopy confirming esophagitis without any signs of hemorrhage. Supporting documentation would include endoscopic findings, pathology reports, and physician notes detailing the diagnosis.

• Ensure documentation explicitly states "without bleeding" or similar phrasing; otherwise, a different subcategory of K21 may be more appropriate.
• Do not confuse this with K21.01 (with bleeding), which requires clear documentation of active or recent hemorrhage.
• Always sequence this code as the primary diagnosis if it is the main reason for the encounter, unless another condition is clearly identified as the principal diagnosis.