Gastro-esophageal reflux disease without esophagitis

This code represents the presence of gastroesophageal reflux disease (GERD) where there is no documented inflammation or damage to the esophageal lining. Patients typically experience symptoms such as heartburn, regurgitation, or chest pain, but endoscopic examination or biopsy does not reveal esophagitis.

Use this code when the provider explicitly diagnoses GERD without any mention of esophagitis, or when diagnostic workup (e.g., endoscopy) rules out esophagitis despite GERD symptoms. Documentation should clearly state "GERD without esophagitis" or similar phrasing indicating the absence of esophageal inflammation.

• Do not use this code if esophagitis is documented; instead, select a more specific code from the K21.0- series.
• Ensure the medical record clearly distinguishes between symptomatic GERD and GERD with documented esophageal mucosal injury.
• This code is often used when initial GERD symptoms are present, and further diagnostic evaluation is pending or has ruled out esophagitis.