Malnutrition ICD-10-CM codes

Protein-calorie malnutrition is coded by severity: E43 unspecified severe protein-calorie malnutrition, E44.0 moderate, E44.1 mild, and E46 unspecified protein-calorie malnutrition when the severity is not documented. The severity must come from the provider; a dietitian's assessment can support a query and can be used for the BMI, but the malnutrition diagnosis and its severity must be documented by the treating physician or other qualified provider. E43 is a major complication or comorbidity on inpatient claims and is a recurring target of payer and OIG audits, so clinical indicators such as weight loss, intake, and muscle or fat loss should be documented.

E40 kwashiorkor, E41 nutritional marasmus, and E42 marasmic kwashiorkor describe specific severe deficiency syndromes seen mainly in famine settings and are almost never appropriate for hospitalized adults in the United States; do not assign them because the note uses the word marasmus loosely without the clinical picture. E45 is retarded development following protein-calorie malnutrition and E64.0 is sequelae of protein-calorie malnutrition, both used after the malnutrition itself has resolved.

Cachexia (R64) is a wasting syndrome associated with cancer, heart failure, or other chronic illness; when the provider documents both cachexia and severe malnutrition, both codes are reported. Adult failure to thrive is R62.7 and pediatric failure to thrive is R62.51. Add the BMI code from Z68 (Z68.18 for an adult BMI of 18.4 or less, Z68.19 for 18.5 to 19.9) as an additional code only when a related weight diagnosis such as malnutrition or underweight is documented by the provider. Malnutrition in a patient with an underlying cause, such as cancer or Crohn disease, is coded with the cause as well.