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ICD-10 Guide
ICD-10 CodesE44.1

E44.1

Billable

Mild protein-calorie malnutrition

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 E44.1 is a billable code used to indicate a diagnosis of mild protein-calorie malnutrition.

Key Diagnostic Point:

Mild protein-calorie malnutrition is a condition characterized by a deficiency in protein and calorie intake, leading to a state of undernutrition. This condition is often seen in individuals with inadequate dietary intake due to various factors such as socioeconomic status, chronic illness, or poor dietary habits. Clinically, patients may present with subtle signs such as slight weight loss, decreased muscle mass, and fatigue. Unlike more severe forms of malnutrition, such as kwashiorkor or marasmus, mild protein-calorie malnutrition may not exhibit overt clinical symptoms but can still have significant health implications if left unaddressed. It is essential to identify and manage this condition early to prevent progression to more severe malnutrition states. Nutritional deficiencies can lead to impaired immune function, delayed wound healing, and increased susceptibility to infections. The diagnosis is typically made through a combination of clinical assessment, dietary history, and laboratory tests that evaluate nutritional status. Treatment involves dietary modifications to increase caloric and protein intake, often supplemented by nutritional counseling and education.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation among patients
  • Need for comprehensive dietary assessment
  • Differentiation from other malnutrition types
  • Potential overlap with other ICD-10 codes

Audit Risk Factors

  • Inadequate documentation of dietary intake
  • Failure to specify severity of malnutrition
  • Lack of follow-up on treatment outcomes
  • Misclassification with other malnutrition codes

Specialty Focus

Medical Specialties

Nutritionist/Dietitian

Documentation Requirements

Detailed dietary assessments and nutritional plans must be documented.

Common Clinical Scenarios

Patients with chronic illnesses requiring dietary modifications.

Billing Considerations

Ensure that all dietary recommendations are supported by clinical evidence.

Pediatrics

Documentation Requirements

Growth charts and developmental assessments should be included.

Common Clinical Scenarios

Children with growth delays or feeding difficulties.

Billing Considerations

Consider age-specific nutritional needs and developmental milestones.

Coding Guidelines

Inclusion Criteria

Use E44.1 When
  • According to ICD
  • 10 coding guidelines, E44
  • 1 should be used when there is clear documentation of mild protein
  • calorie malnutrition
  • It is important to include the duration and any associated conditions that may contribute to the malnutrition

Exclusion Criteria

Do NOT use E44.1 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

97802CPT Code

Medical nutrition therapy, individual, face-to-face

Clinical Scenario

Used when a patient is referred for dietary counseling due to malnutrition.

Documentation Requirements

Document the patient's nutritional assessment and treatment plan.

Specialty Considerations

Nutritionists should ensure that the therapy aligns with the diagnosis.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of malnutrition types, improving the accuracy of diagnosis and treatment tracking. E44.1 provides a clear distinction for mild cases, which helps in tailoring nutritional interventions.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of malnutrition types, improving the accuracy of diagnosis and treatment tracking. E44.1 provides a clear distinction for mild cases, which helps in tailoring nutritional interventions.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of malnutrition types, improving the accuracy of diagnosis and treatment tracking. E44.1 provides a clear distinction for mild cases, which helps in tailoring nutritional interventions.

Resources

Clinical References

  • •
    World Health Organization - Malnutrition

Coding & Billing References

  • •
    World Health Organization - Malnutrition

Frequently Asked Questions

What are the common causes of mild protein-calorie malnutrition?

Common causes include inadequate dietary intake due to socioeconomic factors, chronic illnesses, and poor appetite. It can also occur in individuals with restrictive diets or those who have difficulty accessing food.