Find information on ulcerative esophagitis diagnosis, including clinical documentation requirements, ICD-10-CM code K22.1, medical coding guidelines, and healthcare resources. Learn about symptoms, causes, treatment options, and endoscopic findings associated with ulcerative esophagitis for accurate medical recordkeeping and billing. This resource provides comprehensive information for physicians, coders, and other healthcare professionals dealing with esophageal ulcers and inflammation.
Also known as
Diseases of esophagus
Covers various esophageal conditions, including ulcerative esophagitis.
Ulcer of esophagus
Specifically designates ulcers within the esophagus.
Esophagitis, unspecified
Used when the specific type of esophagitis is not documented.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the esophagitis due to reflux?
Yes
Code K21.0, Reflux esophagitis
No
Is the esophagitis due to medication?
When to use each related code
| Description |
|---|
| Ulcerative inflammation of the esophagus |
| Reflux esophagitis (GERD) |
| Eosinophilic esophagitis (EoE) |
Coding K22.9 (Unspecified Esophagitis) without proper documentation of cause when ulcerative esophagitis is suspected. Impacts DRG and reimbursement.
Lack of EGD findings details like location, extent, and severity in documentation leading to inaccurate coding of ulcerative esophagitis severity.
Failure to document the cause of ulcerative esophagitis (e.g., medication, reflux, infection) affecting accurate coding and quality reporting.
Patient presents with complaints consistent with ulcerative esophagitis. Symptoms include odynophagia, dysphagia, retrosternal chest pain, heartburn, and water brash. Onset of symptoms is reported as gradual over the past two weeks and exacerbated by swallowing solids and hot liquids. Patient denies hematemesis or melena but reports occasional nausea and a sour taste in the mouth. Medical history significant for GERD, treated with omeprazole 20mg daily, which provides incomplete symptom relief. Patient also reports use of ibuprofen for occasional headaches. Physical examination reveals no acute distress. Endoscopy findings reveal multiple shallow ulcers in the distal esophagus, consistent with a diagnosis of ulcerative esophagitis. Biopsies were taken and sent for histopathological analysis to rule out infectious esophagitis, eosinophilic esophagitis, and Barrett's esophagus. Differential diagnosis includes medication-induced esophagitis, reflux esophagitis, and infectious esophagitis. Assessment: Ulcerative esophagitis likely secondary to a combination of GERD and NSAID use. Plan: Discontinue ibuprofen. Prescribe pantoprazole 40mg twice daily for eight weeks. Recommend lifestyle modifications including dietary changes, weight management, and elevation of the head of the bed. Follow-up endoscopy scheduled in eight weeks to assess healing and rule out complications. Patient education provided on medication adherence, symptom management, and potential complications of ulcerative esophagitis. ICD-10 code K22.1 assigned. CPT codes for endoscopy and biopsy procedures documented.