Patient presents with complaints consistent with gastroesophageal reflux disease (GERD), including heartburn, acid reflux, regurgitation, and dyspepsia.  The patient describes the heartburn as a burning sensation in the chest, often occurring after meals and worsening when lying down.  Regurgitation of acidic fluid into the mouth is also reported.  Symptoms have been present for approximately [duration] and are impacting the patient's quality of life, specifically [mention specific impact, e.g., sleep disruption, difficulty eating].  The patient denies dysphagia, odynophagia, or weight loss.  Physical examination is unremarkable.  Differential diagnosis includes esophageal spasm, peptic ulcer disease, and angina.  Based on the patient's presenting symptoms and history, a diagnosis of GERD is suspected.  Initial management includes lifestyle modifications, such as dietary changes (avoiding trigger foods like caffeine, alcohol, fatty foods, and spicy foods), weight management if applicable, and elevating the head of the bed.  Pharmacological therapy with an over-the-counter proton pump inhibitor (PPI) is recommended.  Patient education provided regarding GERD management, potential complications such as Barrett's esophagus, and the importance of follow-up.  The patient will be reevaluated in [timeframe] to assess symptom response to therapy.  If symptoms persist or worsen, further investigation with upper endoscopy may be considered.  ICD-10 code K21.9 (Gastro-esophageal reflux disease without esophagitis) is assigned, pending further diagnostic evaluation.  CPT codes for the evaluation and management visit will be determined based on the complexity of the encounter.