Protein-Calorie Malnutrition HCC Coding Guide
Protein-Calorie Malnutrition (e.g. E43) does not map to a payment Hierarchical Condition Category under the CMS-HCC V28 model (100% phase-in for payment year 2026), so these codes do not raise a patient's RAF score. Document them accurately for clinical and quality purposes, but expect no V28 risk-adjustment credit.
Complete HCC coding guide for Protein-Calorie Malnutrition (E40-E46) including ICD-10 to HCC mapping, V28 RAF weights, severity documentation, and BMI coding.
Medically reviewed by Jess P., CPC · Reviewed: May 9, 2026 · Updated for CMS-HCC V28 and FY2026 ICD-10-CM
Quick Facts
HCC Categories
RAF Weight Range
No payment HCC (V28)
Community, non-dual, aged (V28)
Model
CMS-HCC V28 (PY2026, 100% phase-in)
0 ICD-10 codes map to payment HCCs
What HCC category does Protein-Calorie Malnutrition map to under V28?
Protein-calorie malnutrition (PCM) describes a spectrum of nutritional deficiency states, from mild and moderate to severe forms such as kwashiorkor and marasmus. It is diagnosed on clinical grounds, unintentional weight loss, inadequate intake, muscle wasting, and subcutaneous fat loss, often framed by the ASPEN and Academy of Nutrition and Dietetics consensus criteria. Labs such as albumin and prealbumin support but never establish the diagnosis. Here is the part many coders miss in 2026, under CMS-HCC V28 (PY2026) the protein-calorie malnutrition codes (E40 to E46) and cachexia (R64) no longer map to any payment HCC. They risk-adjusted under the older V24 model but were dropped in V28. Document type and severity precisely, the diagnosis still drives quality measures and care, even without an HCC.
ICD-10 to HCC Mapping
| ICD-10 Code | Description | Billable | HCC Mapping |
|---|---|---|---|
| E43 | Unspecified severe protein-calorie malnutrition | Yes | No HCC (not risk-adjusting under V28) |
| E44.0 | Moderate protein-calorie malnutrition | Yes | No HCC (not risk-adjusting under V28) |
| E44.1 | Mild protein-calorie malnutrition | Yes | No HCC (not risk-adjusting under V28) |
| E46 | Unspecified protein-calorie malnutrition | Yes | No HCC (not risk-adjusting under V28) |
| E40 | Kwashiorkor | Yes | No HCC (not risk-adjusting under V28) |
| E41 | Nutritional marasmus | Yes | No HCC (not risk-adjusting under V28) |
| E42 | Marasmic kwashiorkor | Yes | No HCC (not risk-adjusting under V28) |
| E45 | Retarded development following protein-calorie malnutrition | Yes | No HCC (not risk-adjusting under V28) |
| R64 | Cachexia | Yes | No HCC (not risk-adjusting under V28) |
| R63.4 | Abnormal weight loss | Yes | No HCC (not risk-adjusting under V28) |
RAF weights are community, non-dual, aged base coefficients from the CMS-HCC V28 model (PY2026). Verify against the latest CMS rate announcement for payment calculations.
HCC Buddy maps Protein-Calorie Malnutrition from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Documentation Tips
The provider must explicitly diagnose 'malnutrition' or 'protein-calorie malnutrition', coders cannot assign these codes based on lab values or BMI alone.
Document the severity: mild, moderate, or severe based on ASPEN or Academy of Nutrition and Dietetics criteria.
Record the clinical indicators: unintentional weight loss (percentage and timeframe), reduced oral intake, muscle wasting, subcutaneous fat loss.
Include supporting lab values: albumin, prealbumin, transferrin, but remember these alone do not establish the diagnosis.
Document the treatment plan: nutritional supplementation, dietary modifications, enteral/parenteral nutrition orders.
Registered dietitian assessments can support the diagnosis, but the attending provider must document and confirm the malnutrition diagnosis.
Re-evaluate and re-document malnutrition status at subsequent encounters to demonstrate ongoing assessment and treatment.
Common Coding Mistakes
Assigning a malnutrition code based solely on low albumin or BMI without a provider diagnosis of malnutrition.
Using E46 (unspecified PCM) when the provider has documented the severity, always code to the most specific severity level.
Not recapturing malnutrition at follow-up encounters when the condition persists, it must be re-documented and coded each visit.
Failing to have the attending physician co-sign or confirm a dietitian's malnutrition assessment, which is required for coding purposes.
Coding malnutrition for patients who are simply underweight without documented clinical malnutrition criteria.
V24 to V28 Changes
This is one of the more consequential V28 changes for nutrition coding. Under the prior V24 model, protein-calorie malnutrition and cachexia carried a payment HCC with meaningful weight. CMS removed that category in CMS-HCC V28, so for PY2026 the E40 to E46 codes and R64 (Cachexia) map to no V28 payment HCC and no longer raise a patient RAF score. Coders should not expect risk-adjustment credit from these codes going forward, and should be cautious with any guidance still citing an old malnutrition HCC. Keep coding them accurately, they remain clinically important and audit-relevant, but treat them as documentation and quality drivers, not as V28 risk-adjusting diagnoses.
Related Conditions
Related references
Sources
RAF weights are community, non-dual, aged base coefficients from the CMS-HCC V28 model (PY2026). Verify against the latest CMS Rate Announcement for payment.
Verified current to CMS-HCC V28, payment year 2026 — last reviewed May 9, 2026.
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