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v1.0.0
ICD-10 Guide
ICD-10 CodesR46.0

R46.0

Very low level of personal hygiene

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 R46.0 is a billable code used to indicate a diagnosis of very low level of personal hygiene.

Key Diagnostic Point:

R46.0 refers to a very low level of personal hygiene, which can manifest as neglect in personal grooming, cleanliness, and overall self-care. This condition may be observed in various clinical settings and can be indicative of underlying psychological issues, such as depression, schizophrenia, or other mental health disorders. It may also arise from physical disabilities, cognitive impairments, or socio-economic factors that limit access to hygiene resources. Clinicians should assess the patient's living conditions, mental health status, and any physical limitations that may contribute to this finding. The presence of very low personal hygiene can lead to further health complications, including skin infections, social isolation, and exacerbation of existing health conditions. Proper documentation of the patient's hygiene status, associated symptoms, and any relevant social determinants of health is crucial for accurate coding and treatment planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in patient presentation and underlying causes
  • Need for comprehensive documentation of contributing factors
  • Potential overlap with mental health diagnoses
  • Subjectivity in assessing hygiene levels

Audit Risk Factors

  • Inadequate documentation of the patient's hygiene status
  • Failure to link hygiene issues to underlying medical or psychological conditions
  • Misclassification of hygiene issues as purely behavioral without considering medical factors
  • Lack of interdisciplinary notes that support the diagnosis

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed notes on the patient's hygiene status, associated medical conditions, and any psychosocial factors.

Common Clinical Scenarios

Patients with chronic illnesses who may neglect personal care due to fatigue or depression.

Billing Considerations

Consider the impact of comorbidities on the patient's ability to maintain hygiene.

Emergency Medicine

Documentation Requirements

Acute assessment of hygiene status, including any immediate health risks associated with poor hygiene.

Common Clinical Scenarios

Patients presenting with infections or skin conditions related to poor hygiene.

Billing Considerations

Rapid assessment and documentation are crucial in emergency settings.

Coding Guidelines

Inclusion Criteria

Use R46.0 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that R46
  • 0 is used only when very low personal hygiene is clearly documented and linked to the patient's overall health status

Exclusion Criteria

Do NOT use R46.0 When
No specific exclusions found.

Related CPT Codes

99214CPT Code

Established patient office visit, level 4

Clinical Scenario

Used when assessing a patient with very low personal hygiene during a routine visit.

Documentation Requirements

Document the patient's hygiene status and any related health issues.

Specialty Considerations

Internal medicine providers should focus on the holistic assessment of the patient.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of personal hygiene issues, enabling better tracking of related health outcomes and facilitating targeted interventions.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of personal hygiene issues, enabling better tracking of related health outcomes and facilitating targeted interventions.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of personal hygiene issues, enabling better tracking of related health outcomes and facilitating targeted interventions.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What should be documented to support the use of R46.0?

Document the patient's hygiene status, any underlying medical or psychological conditions, and the impact of these factors on their overall health.