ICD-10 Coding for Underweight(R63.6)
Complete ICD-10-CM coding and documentation guide for Underweight. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Underweight
Key Information: Can BMI alone justify coding for underweight?
Essential facts and insights about Underweight
Primary ICD-10-CM Code for underweight
Decision Criteria
clinical Criteria
- BMI less than 18.5 with provider documentation
documentation Criteria
- Provider explicitly states 'underweight' linked to clinical findings
Applicable To
- Clinically significant low body weight
Clinical Validation Requirements
- Provider-documented 'underweight'
- BMI less than 18.5
- Weight loss percentage over time
Code-Specific Risks
- Coding based solely on BMI without provider documentation
- Not linking underweight to an underlying cause
Coding Notes
- Ensure provider documentation explicitly states 'underweight' and includes clinical findings.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Underweight to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code R63.6.
Impact
Clinical: May lead to misinterpretation of patient's health status., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims or reduced reimbursement.
Mitigation Strategy
Ensure provider links BMI to clinical diagnosis, Use templates to guide documentation
Impact
Reimbursement: May result in lower reimbursement if not properly documented., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data representation of patient condition.
Mitigation Strategy
Ensure provider documents 'underweight' and links it to clinical findings.
Impact
Risk of audits if underweight is coded without proper provider documentation.
Mitigation Strategy
Ensure all documentation includes provider diagnosis and clinical findings.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Underweight, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Underweight
Use these documentation templates to ensure complete and accurate documentation for Underweight. These templates include all required elements for proper coding and billing.
Adult with unintentional weight loss
Specialty: Internal MedicineRequired Elements
- BMI documentation
- Weight history
- Clinical indicators like muscle wasting
- Provider's diagnosis
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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