A Patient Can’t Have Both GERD With and Without Esophagitis
Question: Two of my gastrointestinal (GI) doctors have listed both gastroesophageal reflux disease (GERD) with esophagitis and GERD without esophagitis in the patient's chart for the same visit. Is it possible to have both? South Carolina Subscriber Answer: No, a patient can’t be diagnosed with both for the current date of service. The patient either has esophagitis (such as, K21.0-, [Gastro-esophageal reflux disease with esophagitis]) or they don’t (K21.9, [Gastro-esophageal reflux disease without esophagitis]). That said, it’s certainly possible that the patient had esophagitis in the past that has since resolved, or they may have newly developed it. If both “with” and “without esophagitis” appear in the problem list or past medical history, that could simply reflect changes over time. If the problem list says “without esophagitis” but the assessment explicitly documents a current diagnosis of esophagitis, follow the assessment. However, if both “with” and “without” appear in the assessment for the same date of service, that’s a conflict. The provider’s documentation should ideally clarify the patient’s current condition. If it doesn’t, you’ll need to query the provider for clarification. Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
