Gastro-esophageal reflux dis with esophagitis, with bleed

This code signifies gastro-esophageal reflux disease (GERD) that has led to inflammation of the esophagus (esophagitis) and is currently associated with active bleeding. The bleeding is a direct complication of the reflux-induced esophagitis.

Apply this code when documentation clearly indicates GERD, endoscopic or histological evidence of esophagitis, and a confirmed source of bleeding within the esophagus attributable to the esophagitis. This is typically used for patients presenting with hematemesis, melena, or positive occult blood tests in the context of GERD and esophagitis.

• Ensure the documentation explicitly links the bleeding to the esophagitis caused by GERD.
• Do not use this code if the bleeding is from a different source, such as a gastric ulcer, even if GERD is also present.
• Consider additional codes for the specific type of bleeding (e.g., hematemesis, melena) if documented, as appropriate.