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E42 ICD-10-CM Code: Marasmic kwashiorkor

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FY 2026 Apr update / Endocrine, nutritional and metabolic diseases (E00-E89) / Malnutrition (E40-E46)

E42

Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidance

Marasmic kwashiorkor

A combination of both kwashiorkor and marasmus, representing the most severe form of protein-calorie malnutrition with both edema and severe wasting.

Buddy the Bee presenting code insight

Buddy Insight

Marasmic kwashiorkor represents the most severe overlap form of protein-calorie malnutrition, combining the severe muscle and fat wasting of marasmus with the edema and hypoalbuminemia of kwashiorkor.

CMS-HCC V28

N/A

—

Not mapped

CMS-HCC V24

HCC 21

RAF 0.455

ACA/HHS

HCC 23

Varies by metal level

ESRD/PACE

HCC 21

RAF 0.068

RXHCC

N/A

—

Not mapped

Code Book Path

Official
E4Malnutrition (E40-E46)
E42Marasmic kwashiorkor

Inclusion Terms

Official
  • Intermediate form severe protein-calorie malnutrition
  • Severe protein-calorie malnutrition with signs of both kwashiorkor and marasmus

Excludes 2

Official

ICD-10-CM does not list Excludes 2 notes for E42 in this effective period.

Related Child Codes

Official

ICD-10-CM does not list child codes under E42 for this display context.

Includes

Official

ICD-10-CM does not list Includes notes for E42 in this effective period.

Excludes 1

Official

ICD-10-CM does not list Excludes 1 notes for E42 in this effective period.

Code First

Official

ICD-10-CM does not list Code First sequencing instructions for E42 in this effective period.

Use Additional

Official

ICD-10-CM does not list Use Additional Code instructions for E42 in this effective period.

Code Also

Official

ICD-10-CM does not list Code Also instructions for E42 in this effective period.

Buddy Documentation Tip

HCC Buddy guidance
Documentation must describe both severe wasting (loss of subcutaneous fat and muscle) and bilateral pitting edema occurring simultaneously.
Laboratory values including serum albumin, prealbumin, transferrin, and electrolytes are required.
The provider should document the underlying cause, comprehensive nutritional assessment, and a detailed refeeding plan.
Complications including infection, electrolyte abnormalities, and organ dysfunction must be recorded.

MEAT Support

HCC Buddy guidance
Documentation must describe both severe wasting (loss of subcutaneous fat and muscle) and bilateral pitting edema occurring simultaneously.
Laboratory values including serum albumin, prealbumin, transferrin, and electrolytes are required.
The provider should document the underlying cause, comprehensive nutritional assessment, and a detailed refeeding plan.
Complications including infection, electrolyte abnormalities, and organ dysfunction must be recorded.

Audit Caution

HCC Buddy guidance
Both severe wasting and edema must be documented by the provider to assign this code.
Do not assume marasmic kwashiorkor simply because a malnourished patient has edema, as other causes of edema must be ruled out.
This code represents the most severe malnutrition category and should only be assigned when documentation clearly supports both components.
Monitor for refeeding syndrome during treatment.

Common Mistakes

HCC Buddy guidance
E40 (Kwashiorkor) has edema but without the severe wasting component.
E41 (Nutritional marasmus) has severe wasting but without edema.
E43 (Unspecified severe protein-calorie malnutrition) is used when the type cannot be determined.
Do not confuse with anasarca from heart failure (I50.x) or nephrotic syndrome (N04.x) superimposed on cachexia.

Current with CMS: FY2026 ICD-10-CM Apr 1 update (effective Apr 1 – Sep 30, 2026) · CMS-HCC V28, 100% phased in for payment year 2026. FY2027 code set already staged for October 1, 2026. How HCC Buddy stays current →

Is E42 an HCC code?

Yes. E42 maps to Protein-Calorie Malnutrition under the V24 model but is not retained in V28.

Code
E42
Description
Marasmic kwashiorkor
HCC (V28)
No CMS-HCC V28 mapping
RAF
—
Billable
Yes
Payment year
2026

HCC Category Mapping

V24HCC 21, Protein-Calorie Malnutrition
0.455
ESRDHCC 21, Protein-Calorie Malnutrition
0.068

Each model's RAF is its CMS base weight for that model's standard population, so weights are not directly comparable across models: CMS-HCC V28 and V24 use Community, Non-Dual, Aged; ESRD uses the dialysis continuing-enrollee model; RxHCC is the Part D continuing-enrollee, non-low-income, aged weight (a larger scale than CMS-HCC). ACA/HHS has no single weight — it varies by metal level. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.

Work E42 in the Code Book — tabular path, V28 RAF, and MEAT checklist →

MEAT Criteria for E42

For E42 to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically, it has to be re-documented and supported each calendar year.

  • MMonitor: signs, symptoms, disease progression, or lab trending documented in the note
  • EEvaluate: test results, medication response, or physical findings reviewed by the provider
  • AAssess: explicit mention in the assessment or plan with acknowledgment of status
  • TTreat: medication, referral, procedure, therapy, or counseling tied to the diagnosis

Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed E42 during that encounter, not just copy-forwarded from a problem list.

Coder workflow notes

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What This Code Means

E42 is the ICD-10-CM diagnosis code for marasmic kwashiorkor. A combination of both kwashiorkor and marasmus, representing the most severe form of protein-calorie malnutrition with both edema and severe wasting. E42 sits in the ICD-10-CM chapter for endocrine, nutritional and metabolic diseases (e00-e89), within the section covering malnutrition (e40-e46).

Under the older CMS-HCC V24 model, E42 maps to Protein-Calorie Malnutrition (HCC 21) with a community, non-dual, aged base RAF weight of 0.455. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.

Marasmic kwashiorkor, mixed severe PCM with features of both marasmus and kwashiorkor. Because E42 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. When documentation is ambiguous, coders should issue a provider query rather than assume the highest-specificity variant.

HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for E42 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

  • •Marasmic kwashiorkor, mixed severe PCM with features of both marasmus and kwashiorkor.
  • •A specific combined presentation requiring documentation of both wasting and edema/pigmentation features.
  • •E42 does not map to a V28 payment HCC. Protein-calorie malnutrition is not risk-adjusted in V28; code it accurately for clinical completeness only.

Clinical Significance

Marasmic kwashiorkor represents the most severe overlap form of protein-calorie malnutrition, combining the severe muscle and fat wasting of marasmus with the edema and hypoalbuminemia of kwashiorkor. This dual presentation indicates extreme nutritional depletion and carries the highest mortality risk among malnutrition syndromes, requiring immediate and carefully managed nutritional intervention.

Documentation Requirements

  • ✓Documentation must describe both severe wasting (loss of subcutaneous fat and muscle) and bilateral pitting edema occurring simultaneously.
  • ✓Laboratory values including serum albumin, prealbumin, transferrin, and electrolytes are required.
  • ✓The provider should document the underlying cause, comprehensive nutritional assessment, and a detailed refeeding plan.
  • ✓Complications including infection, electrolyte abnormalities, and organ dysfunction must be recorded.

Commonly Confused Codes

  • •E40 (Kwashiorkor) has edema but without the severe wasting component.
  • •E41 (Nutritional marasmus) has severe wasting but without edema.
  • •E43 (Unspecified severe protein-calorie malnutrition) is used when the type cannot be determined.
  • •Do not confuse with anasarca from heart failure (I50.x) or nephrotic syndrome (N04.x) superimposed on cachexia.

Code Hierarchy

└E42Marasmic kwashiorkor
└E42Marasmic kwashiorkor

Because E42 maps to a payment HCC, the documentation must also satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's risk adjustment score.

More on E42

Related condition guides

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