Understanding Poor Oral Intake: Find information on diagnosis, clinical documentation, and medical coding for inadequate oral intake. Explore resources related to decreased appetite, dysphagia, feeding difficulties, malnutrition, dehydration, and weight loss associated with poor oral intake. Learn about relevant ICD-10 codes, SNOMED CT concepts, and clinical terminology for accurate medical record keeping and improved patient care. This resource offers guidance for healthcare professionals on managing and documenting cases of reduced oral consumption.
Also known as
Anorexia
Lack or loss of appetite resulting in reduced food intake.
Dysphagia
Difficulty or discomfort in swallowing, hindering oral intake.
Eating disorders
Conditions characterized by abnormal eating patterns impacting intake.
Falls
May lead to injury preventing normal food intake.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the poor oral intake due to a mental disorder?
Yes
Is it Avoidant/Restrictive Food Intake Disorder?
No
Is it due to a general medical condition?
When to use each related code
| Description |
|---|
| Poor appetite or intake |
| Feeding difficulties |
| Malnutrition |
Coding Poor Oral Intake without documenting the underlying cause risks inaccurate DRG assignment and lost revenue.
Symptoms like nausea or dysphagia may be the cause. Coding both separately leads to overcoding and potential audits.
Generalized documentation lacks the detail needed for accurate code assignment and may trigger clinical validation denials.
Patient presents with poor oral intake, characterized by inadequate consumption of food and fluids. Symptoms include decreased appetite, difficulty chewing or swallowing (dysphagia), early satiety, nausea, vomiting, and weight loss or failure to thrive in pediatric patients. Contributing factors may include medical conditions such as gastrointestinal disorders, infections, neurological conditions, psychological factors like depression or anxiety, dental issues, medication side effects, or social determinants of health such as limited access to food. Assessment includes a detailed dietary history, review of symptoms, physical examination, and potential laboratory tests to evaluate nutritional status and identify underlying causes. Diagnosis of poor oral intake is based on clinical findings and corroborating evidence. The differential diagnosis includes anorexia nervosa, bulimia nervosa, avoidant restrictive food intake disorder (ARFID), and other medical conditions causing decreased appetite. Treatment plan focuses on addressing the underlying cause and may include nutritional counseling, dietary modifications, speech therapy for swallowing difficulties, medication management, behavioral interventions, and or referral to other specialists as appropriate. Monitoring of weight, intake, and overall clinical status is crucial. ICD-10 codes related to poor oral intake may include R63.0 (Anorexia), R63.3 (Feeding difficulties), or other codes depending on the specific etiology. This documentation supports medical necessity for interventions and facilitates accurate medical billing and coding.