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Gastro-oesophageal Reflux Disease J002

Document
Last amended 
2 December 2015
Current RMA Instruments:
Reasonable Hypothesis SOP
65 of 2013
Balance of Probabilities SOP
66 of 2013
Changes from previous instruments:

SOP Bulletin 167

ICD Coding:
  • ICD-9-CM:  530.11,530.2,530.81
  • ICD-10-AM: K21
   Brief description

This SOP covers gastric reflux of sufficient severity to result in chronic inflammation of the oesophagus. Minor symptomatic reflux without oesophagitis is very common, but is not a disease.

Confirming the diagnosis

Diagnosis requires chronic symptoms consistent with oesophagitis, or, preferably, reflux oesophagitis confirmed by upper gastrointestinal endoscopy.

The relevant medical specialist is a gastroenterologist.

Additional diagnoses covered by SOP
  • Reflux oesophagitis
Related conditions that may be covered by SOP (further information required)
  • Heartburn
  • Waterbrash
  • Oesophagitis unspecified
Conditions not covered by SOP
  • Oesophagitis due to radiation, infectious agents or corrosive agents#
  • Barrett’s oesophagus (metaplasia), ICD-9 code 530.85; ICD-10 code K22.7. This can be considered as a (separate) complication of gastro-oesophageal reflux disease.

# non-SOP condition

Clinical onset

An accurate clinical onset may be difficult to establish.  Once the diagnosis has been confirmed and other causes of heartburn-type symptoms have been excluded, clinical onset can be backdated to when chronic (persistent, long term) symptoms of heartburn, accompanied by regurgitation, first developed.

Clinical worsening

Permanent clinical worsening could be manifest by a persisting increase in the level of symptoms or the development of oesophageal ulcer, bleeding or stricture.  Barrett's oesophagus is a separate condition , not a worsening of GORD.