**Medical Coding Cheat Sheet Documentation Template:  Gastroesophageal Reflux Disease (GERD)**

Patient presents with complaints consistent with gastroesophageal reflux disease (GERD), including heartburn, acid reflux, regurgitation, and dyspepsia.  The patient reports postprandial burning sensation in the retrosternal area radiating upwards, often exacerbated by lying down or bending over.  Symptoms occur approximately three times per week and have been ongoing for the past six months.  The patient denies dysphagia, odynophagia, or unintentional weight loss.  Physical examination reveals no significant abnormalities.  Assessment:  Gastroesophageal reflux disease (GERD).  Plan:  Lifestyle modifications including dietary changes, weight management if indicated, and elevation of the head of the bed.  Initiate trial of proton pump inhibitor therapy with omeprazole 20mg daily.  Patient education provided regarding GERD management, including trigger avoidance and medication compliance.  Follow-up scheduled in four weeks to assess symptom improvement and discuss further management options if necessary.  Differential diagnoses considered include esophageal spasm, peptic ulcer disease, and hiatal hernia.  Medical coding considerations include ICD-10-CM code K21.9 for GERD and relevant CPT codes for office visit and therapeutic procedures if performed.  This documentation supports medical necessity for prescribed treatment and facilitates accurate medical billing and coding for reimbursement purposes.