Abnormal weight loss
ICD-10 R63.4 is a billable code used to indicate a diagnosis of abnormal weight loss.
Abnormal weight loss is defined as a significant decrease in body weight that is not attributed to a specific medical condition or intentional weight loss efforts. It is often characterized by a loss of 5% or more of body weight over a period of 6 to 12 months. This symptom can arise from various underlying causes, including metabolic disorders, malignancies, gastrointestinal diseases, chronic infections, and psychiatric conditions such as depression or eating disorders. Clinically, abnormal weight loss may present with accompanying symptoms such as fatigue, weakness, changes in appetite, and alterations in bowel habits. Laboratory findings may reveal electrolyte imbalances, anemia, or signs of malnutrition. The identification of abnormal weight loss necessitates a thorough clinical evaluation to determine the underlying etiology, which may include a detailed patient history, physical examination, and targeted diagnostic testing.
Detailed patient history, including duration and context of weight loss, associated symptoms, and any relevant medical history.
Patients presenting with unexplained weight loss during routine check-ups or follow-up visits for chronic conditions.
Consideration of comorbidities and the need for a multidisciplinary approach to management.
Acute presentation documentation, including vital signs, initial assessment findings, and any immediate interventions.
Patients presenting to the emergency department with significant weight loss and acute symptoms such as dehydration or weakness.
Rapid assessment and stabilization of patients, with emphasis on ruling out life-threatening conditions.
Used for follow-up visits to monitor weight loss and assess underlying conditions.
Document weight loss details, associated symptoms, and any diagnostic tests performed.
Internal medicine may require more comprehensive documentation compared to other specialties.
Abnormal weight loss is typically defined as a loss of 5% or more of body weight over 6 to 12 months without intentional efforts to lose weight.
