Underweight
ICD-10 R63.6 is a billable code used to indicate a diagnosis of underweight.
Underweight is defined as a body weight that is significantly lower than what is considered normal or healthy for a given height, often indicated by a Body Mass Index (BMI) of less than 18.5. This condition can arise from various factors, including inadequate caloric intake, malabsorption syndromes, chronic illnesses, or psychological conditions such as anorexia nervosa. Clinically, underweight individuals may present with signs such as muscle wasting, fatigue, and a weakened immune response. Laboratory findings may reveal electrolyte imbalances, anemia, or deficiencies in vitamins and minerals. It is crucial to assess the underlying causes of underweight, as it can lead to serious health complications, including osteoporosis, infertility, and increased mortality risk. A thorough clinical evaluation, including dietary history, physical examination, and relevant laboratory tests, is essential for accurate diagnosis and management.
Detailed patient history, physical examination findings, and laboratory results must be documented to support the diagnosis of underweight.
Patients presenting with unexplained weight loss, chronic illnesses, or nutritional deficiencies.
Consideration of comorbid conditions that may contribute to underweight, such as hyperthyroidism or chronic infections.
Acute care documentation should include vital signs, weight, and any immediate interventions taken.
Patients presenting with acute complications related to being underweight, such as dehydration or electrolyte imbalances.
Rapid assessment and stabilization of patients may be necessary, with thorough documentation of findings and interventions.
Used when a patient is referred for nutritional counseling due to underweight.
Documentation of the patient's nutritional status and goals for therapy.
Nutritionists or dietitians may need to provide detailed reports for accurate billing.
Documenting BMI is crucial as it provides a quantitative measure of the patient's weight status, which is necessary for accurate coding and management of underweight.
