Obesity, Protein Calorie Malnutrition and Cachexia Diagnosis and Documentation

Activity description

Maintaining a healthy weight is important for individuals across the lifespan. Individuals who are obese, compared to those with a healthy weight, are at increased risk for serious diseases and health conditions. At the opposite end of the spectrum, protein calorie malnutrition (PCM) and cachexia also cause serious health problems. Obesity is a clinical diagnosis with nomenclature of class I, II or III; however, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding documentation may not directly map to a specific clinical diagnosis. Screening with body mass index and evaluating for comorbidities will help determine if documentation should include that the patient has obesity or has morbid (severe) obesity. PCM is inadequate intake leading to changes in body composition and function. Cachexia, or weakness and wasting of the body, is not caused by PCM alone, but rather is a hypercatabolic state secondary to an advanced chronic condition. Many screening tools exist for PCM. Once diagnosed, PCM should be differentiated from cachexia and one or both should be documented appropriately.

This activity will discuss clinical and coding definitions for obesity, PCM and cachexia and examine appropriate documentation for these conditions.

Provided by
This activity is provided by Optum Health Education and Optum.

Commercial support
No commercial support was received for this activity.

Hardware/Software Requirements
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Target Audience

This activity is designed to meet the educational needs of nurses, physicians and other health care professionals interested in the care of individuals with obesity, PCM or cachexia.

Learning Objectives

At the end of this educational activity, participants should be able to:

  • Describe the clinical and coding definitions for obesity and PCM and how they differ.
  • State examples of when it may be appropriate to document and code for morbid (severe) obesity and PCM vs when it may not be appropriate.
  • Recognize the importance of clinical judgment in diagnosing, documenting and coding obesity and PCM diagnoses.
Activity summary
Available credit: 
  • 1.00 AMA - Physicians
  • 1.00 ANCC - Nurses
  • 1.00 Attendance - General Attendance
Activity opens: 
Activity expires: 

Rebecca Gleason, RN, CCM
Clinical Planner 
Optum Health Education

Monique May, MD, MHA
Medical Director 
Optum Care

Disclosures of relevant financial relationships
In accordance with the Accreditation Council for Continuing Medical Education's (ACCME) Standards for Integrity and Independence in Accredited Continuing Education, OptumHealth Education (OHE) requires all those in control of educational content to disclose their financial relationships with ineligible companies within the prior 24 months. Ineligible companies are defined by the ACCME as companies whose primary business is producing, marketing, selling, re-selling, or distributing health care products used by or on patients. Individuals must disclose all financial relationships, regardless of the amount, with ineligible companies and regardless of their view of the relevance of the relationship to the education. OHE ensures that the content is independent of commercial bias.

The activity faculty or planners have no financial relationships to disclose.

Method for calculating CE credit
CE credit was calculated by the complexity of content.

Accreditation Statement
Joint Accreditation LogoIn support of improving patient care, this activity has been planned and implemented by Optum Health Education and Optum. Optum Health Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE) and the American Nurses Credentialing Center (ANCC), to provide continuing education for the health care team.

Credit Designation Statements
The participant will be awarded up to 1.00 contact hour(s) of credit for attendance and completion of supplemental materials.

Nurse Practitioners
The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts credit from organizations accredited by the ACCME and ANCC.

Optum Health Education designates this enduring activity for a maximum of 1.00 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The American Academy of Physician Assistants (AAPA) accepts credit from organizations accredited by the ACCME.

A certificate of attendance will be provided to learners upon completion of activity requirements, enabling participants to register with licensing boards or associations that have not been pre-approved for credits. To apply for credit types not listed above, participants should use the procedure established by the specific organization with which they wish to obtain credit.

Available Credit

  • 1.00 AMA - Physicians
  • 1.00 ANCC - Nurses
  • 1.00 Attendance - General Attendance
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