Understand wasting syndrome diagnosis, clinical features, and ICD-10 coding (R64). Learn about documenting cachexia, weight loss, muscle atrophy, and malnutrition in healthcare settings. Find information on associated conditions, treatment options, and best practices for accurate medical coding and clinical documentation related to wasting syndrome. Explore resources for healthcare professionals, including diagnostic criteria and coding guidelines.
Also known as
Cachexia
Severe weight and muscle loss, often due to chronic illness.
Malnutrition
Deficiencies in nutrients causing health problems.
Constitutional delay in growth
Delayed growth and puberty without underlying disease.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the wasting syndrome associated with HIV?
Yes
Is it wasting syndrome with diarrhea?
No
Is it due to malnutrition?
When to use each related code
| Description |
|---|
| Weight loss and muscle wasting |
| Cachexia |
| Sarcopenia |
Coding R64 without further specification when documentation supports a more specific cause (e.g., HIV-related) leads to inaccurate severity and reimbursement.
Incorrect BMI calculation or documentation can impact accurate diagnosis of wasting (R64) and related malnutrition diagnoses, affecting quality metrics.
Failing to capture underlying conditions contributing to wasting (R64), like malignancy (C00-C97) or gastrointestinal issues (K00-K93), impacts risk adjustment.
Patient presents with wasting syndrome, characterized by involuntary weight loss, muscle atrophy, and weakness. Clinical findings include a documented weight loss of greater than 5% of body weight over six months or greater than 10% over 12 months, in the absence of a primary diagnosis explaining the weight loss. Patient reports decreased appetite, fatigue, and diminished functional capacity. Assessment includes evaluation for underlying medical conditions such as HIV-associated wasting syndrome, cancer cachexia, chronic infections (tuberculosis, endocarditis), gastrointestinal disorders (Crohn's disease, ulcerative colitis), and endocrine disorders (hyperthyroidism, Addison's disease). Diagnostic workup may include complete blood count (CBC), comprehensive metabolic panel (CMP), inflammatory markers (ESR, CRP), HIV testing, thyroid function tests, and imaging studies (chest x-ray, abdominal CT scan) as clinically indicated. Differential diagnosis considers anorexia nervosa, bulimia nervosa, depression, and malabsorption syndromes. Treatment plan focuses on addressing the underlying etiology, nutritional support with high-calorie, high-protein diet, and symptom management. Patient education provided on dietary modifications, importance of follow-up care, and potential complications such as malnutrition and immune dysfunction. ICD-10 code R64 assigned. Referral to registered dietitian and social worker may be warranted for comprehensive nutritional assessment and psychosocial support.