Wiki GERD with and without esophagitis

[PennyG]

Two of my GI docs have listed both GERD with esophagitis and GERD without esophagitis in the patient's chart for the same visit. Is it possible to have both? Thought I would post here before trying to track my providers down. Seems like a stupid question to me, but since I have had it twice, it's got me questioning.

 

[sls314]

Two of my GI docs have listed both GERD with esophagitis and GERD without esophagitis in the patient's chart for the same visit. Is it possible to have both? Thought I would post here before trying to track my providers down. Seems like a stupid question to me, but since I have had it twice, it's got me questioning.

No, it can’t be both for the current date of service - the patient either has esophagitis or they don’t.

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, I would 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.