Current RMA Instruments
| Reasonable Hypothesis SOP | 61 of 2021 |
| Balance of Probabilities SOP | 62 of 2021 |
Changes from previous instruments
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 either cause chronic inflammation of the oesophagus (with histological evidence), or to result in symptoms sufficient to warrant regular medical treatment. Minor symptomatic reflux without oesophagitis is very common, but is not a disease.
Confirming the diagnosis
The diagnosis is based on the clincial presentation (significantly symptomatic reflux) and is preferrably confirmed by upper gastrointestinal endoscopy, with histology. Symptoms may involve the oesophagus (particularly heart burn) but may also include manifestations in the larynx and pharynx (regurgitation, cough, hoarseness).
The relevant medical specialist is a gastroenterologist.
Additional diagnoses covered by SOP
- Reflux oesophagitis
- Reflux with oseophageal ulceration
Related conditions that may be covered by SOP (further information required)
- Heartburn
- Waterbrash
- Oesophagitis unspecified
Conditions not covered by SOP
- Barrett’s oesophagus*
- Oesophagitis due to radiation, infectious agents or corrosive agents#
- Oesophageal varices#
* Another SOP applies
# 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 reflux symptoms of sufficient severity to warrant treatment 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.