2025 ICD-10-CM code R63.4
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Symptoms - Symptoms and signs concerning food and fluid intake Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified Feed
Abnormal weight loss.
No specific modifiers are typically applied to R63.4.
Medical necessity for coding R63.4 is established when a patient presents with significant, unexplained weight loss and when appropriate investigations fail to reveal a specific underlying condition. The documentation must demonstrate that a reasonable effort was made to determine the cause of the weight loss.
The clinical responsibility for coding R63.4 rests with the physician or qualified healthcare professional who conducts a thorough assessment of the patient, including a review of their medical history, physical examination, and any relevant laboratory or imaging results.It is crucial that documentation clearly outlines the investigations undertaken to rule out other potential causes of weight loss before assigning this code.
- Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified
- R63 (Symptoms and signs concerning food and fluid intake)
In simple words: This code means that someone has lost weight without a clear reason. Doctors use this code when they can't figure out why the weight loss is happening.
R63.4 in ICD-10-CM signifies abnormal weight loss, encompassing situations where an individual experiences unintentional or unexplained reduction in body weight.This code is applied when a specific underlying cause for the weight loss cannot be readily identified or when the weight loss is a prominent symptom without a clear diagnosis.The code should be utilized cautiously and only when comprehensive investigations fail to pinpoint a specific etiology.
Example 1: A 55-year-old male presents with unexplained weight loss of 15 pounds over the past three months.Physical examination and laboratory tests are unremarkable.No specific etiology is found after thorough investigation.R63.4 is assigned., A 70-year-old female is admitted to the hospital with general weakness and fatigue. She has experienced significant weight loss (20 lbs) without a clear cause, despite various tests.Extensive evaluations including metabolic screening and imaging studies reveal no specific underlying condition causing weight loss. Therefore, R63.4 is assigned in addition to codes describing the presenting symptoms (e.g., fatigue, weakness)., A 30-year-old female reports unintended weight loss.She denies any dietary changes or increased physical activity.Initial bloodwork is normal. Further tests are planned, but for the initial encounter, R63.4 is assigned as a placeholder pending further diagnostic results.
Detailed patient history including dietary habits, weight changes, medication use, and recent illnesses. Results of any physical examinations, relevant laboratory tests (e.g., complete blood count, metabolic panel), and imaging studies performed.A clear statement indicating the inability to determine a specific cause of the weight loss despite the investigations conducted.
** This code should not be used as a primary diagnosis unless all other possibilities have been reasonably excluded.It serves as a temporary code until a definitive diagnosis is made or when an underlying cause for the weight loss remains elusive despite exhaustive workup.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Internal Medicine, Endocrinology, Gastroenterology, Oncology
- Place of Service:Office, Hospital Inpatient, Hospital Outpatient, Nursing Facility