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R62.51
ICD-10-CM
Poor Weight Gain

Find information on poor weight gain diagnosis, including clinical documentation tips, ICD-10 codes (R62.5, F50.8), and SNOMED CT terminology. Learn about evaluating failure to thrive, pediatric underweight, delayed growth, and nutritional deficiencies related to poor weight gain in infants, children, and adults. Explore resources for healthcare professionals on assessing, documenting, and coding poor weight gain for accurate medical records and effective patient care.

Also known as

Failure to Thrive
FTT
Weight Loss
+1 more

Diagnosis Snapshot

Key Facts
  • Definition : Insufficient weight gain compared to expected growth charts.
  • Clinical Signs : Small size, low body weight, delayed developmental milestones, fatigue.
  • Common Settings : Pediatric clinics, primary care, nutritionist consultations, hospitals.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC R62.51 Coding
R63.6

Feeding difficulties and poor weight gain

Slow or inadequate weight gain in infants and children.

F50.8

Other eating disorders

Includes atypical eating problems that can contribute to poor weight gain.

R62.52

Failure to thrive, child, unspecified

General term for inadequate growth, often including poor weight gain.

E43-E46

Malnutrition

Various forms of undernutrition that can cause significant weight loss or poor gain.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the poor weight gain due to an underlying medical condition?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Poor weight gain in children
Failure to thrive (FTT)
Feeding difficulties

Documentation Best Practices

Documentation Checklist
  • Poor weight gain diagnosis documented
  • Weight-for-age percentile recorded
  • Underlying medical conditions ruled out/addressed
  • Dietary intake and feeding patterns assessed
  • Follow-up plan for weight monitoring documented

Coding and Audit Risks

Common Risks
  • Unspecified Diagnosis

    Coding poor weight gain without specifying underlying cause or clinical details leads to inaccurate reporting and potential payment errors.

  • Lack of Supporting Documentation

    Insufficient documentation of weight trends, dietary intake, and diagnostic workup can cause claim denials and compliance issues.

  • Conflicting Information

    Discrepancies between documented weight, growth charts, and clinical findings can lead to coding errors and affect quality metrics.

Mitigation Tips

Best Practices
  • Document specific ICD-10-CM codes (e.g., R62.51, R63.6) for poor weight gain.
  • CDI: Specify type, onset, and severity of poor weight gain. Include feeding difficulties.
  • Track growth metrics with SNOMED CT codes for accurate pediatric monitoring.
  • Address underlying causes. Optimize nutrition. Dietitian referral if needed. Ensure compliance.
  • Monitor, reassess, and document interventions. Adjust plan as needed per guidelines.

Clinical Decision Support

Checklist
  • Verify insufficient weight gain documented: ICD-10 R62.51
  • Review dietary history, feeding difficulties: SNOMED CT 22536001
  • Assess underlying medical conditions: rule out FTT, malabsorption
  • Check growth chart, calculate BMI/weight-for-age percentile
  • Document parental/caregiver education, follow-up plan

Reimbursement and Quality Metrics

Impact Summary
  • Poor Weight Gain reimbursement hinges on accurate ICD-10 FTT coding (R62.51, 783.4) impacting malnutrition diagnosis related group (DRG) assignment.
  • Coding quality affects malnutrition quality measures like hospital readmissions, patient safety indicators, impacting value-based purchasing.
  • Precise documentation of underlying causes, interventions, and outcomes is crucial for appropriate reimbursement and severity level assignment.
  • Optimizing coding for poor weight gain impacts hospital reporting on malnutrition prevalence, resource utilization, and quality improvement efforts.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Document specific growth chart percentiles
  • Include dietary intake details
  • Code underlying conditions causing PWG
  • Specify FTT vs. other diagnoses
  • Rule out malabsorption with relevant tests

Documentation Templates

Patient presents with poor weight gain, also documented as failure to thrive, faltering growth, or insufficient weight gain, raising concerns for potential underlying medical conditions.  Presenting symptoms include inadequate increase in weight and height percentiles on growth charts, decreased appetite, or feeding difficulties.  A comprehensive review of systems was conducted, encompassing dietary intake, feeding patterns, gastrointestinal function, and any history of vomiting, diarrhea, or constipation.  Family history regarding growth and developmental milestones was also obtained.  Differential diagnosis includes but is not limited to conditions such as gastroesophageal reflux disease (GERD), food allergies or intolerances, celiac disease, cystic fibrosis, congenital heart disease, and metabolic disorders.  Further evaluation may include laboratory testing such as complete blood count (CBC), comprehensive metabolic panel (CMP), thyroid function tests, and stool studies as clinically indicated.  Nutritional assessment including calorie counts and assessment of macronutrient intake will be performed.  Initial treatment plan includes close monitoring of growth parameters, dietary counseling with a focus on increasing caloric density and optimizing nutrition, and addressing any underlying medical conditions.  Referral to a pediatric gastroenterologist or registered dietitian may be considered for specialized management of feeding difficulties and nutritional support.  Patient and family education regarding appropriate feeding techniques, portion sizes, and recognizing signs of feeding problems is crucial.  Follow-up appointments will be scheduled to monitor progress and adjust the treatment plan as needed.  ICD-10 code R62.51 (Failure to thrive, child, nonorganic) or other appropriate codes based on specific etiology will be used for billing and coding purposes.