E46

HCC Category Mapping

What This Code Means

A condition where the body lacks adequate protein and calories, resulting in severe malnutrition and weight loss. The specific cause or type is not documented.

Coding Tips

• •Use this code only when the type of protein-calorie malnutrition (kwashiorkor, marasmus, or mixed) cannot be determined from documentation
• •Review medical record for more specific malnutrition codes (E40-E45) before assigning E46

Clinical Significance

Unspecified protein-calorie malnutrition indicates that a patient has documented malnutrition from inadequate protein and calorie intake, but neither the severity (mild, moderate, or severe) nor the type (kwashiorkor vs. marasmus) has been specified. This code signals a documentation opportunity to obtain greater specificity from the provider, which improves clinical care and audit defensibility.

Documentation Requirements

• ✓Documentation should include the clinical basis for the malnutrition diagnosis, including body mass index, weight trends, laboratory markers (albumin, prealbumin), physical exam findings, and nutritional screening results.
• ✓The provider should be queried to specify severity (mild, moderate, or severe) and type to enable assignment of a more specific code.
• ✓The underlying cause and treatment plan should be documented.

Commonly Confused Codes