Understanding Adult Failure to Thrive (AFTT)
Adult failure to thrive (AFTT) is a syndrome characterized by a state of overall physical and functional decline in an adult, most often the elderly. It is not a singular disease but rather a complex set of indicators that signal a significant change in a patient's health status. The syndrome includes unexplained weight loss, decreased appetite, poor nutrition, and inactivity, often compounded by other issues like dehydration, impaired immune function, depressive symptoms, and cognitive impairment. Because of its multifactorial nature, identifying a single root cause can be difficult.
Unlike pediatric failure to thrive, which focuses on a child's failure to meet growth milestones, adult FTT describes a patient's inability to maintain their functional status, often representing the end stage of frailty syndrome. A diagnosis of AFTT should serve as an alarm bell for healthcare providers to conduct a comprehensive assessment to uncover any reversible underlying illnesses.
Can Adult Failure to Thrive be a Primary Diagnosis for Acute Care?
For acute care admissions, using AFTT as a primary diagnosis is problematic and strongly discouraged by many medical experts and facilities. Studies have shown that older adults admitted with a primary diagnosis of FTT often have an underlying, acute medical condition that is only identified later in their hospital stay. The use of this nonspecific label can lead to diagnostic delays, longer hospital stays, and potentially worse patient outcomes. Instead, clinicians are urged to use more specific symptoms, such as "generalized weakness" or "anorexia," as a working diagnosis while investigations are underway.
Common underlying acute conditions found in patients initially diagnosed with FTT include:
- Infections (e.g., pneumonia, urinary tract infections)
- Cardiac issues (e.g., heart failure, cardiac ischemia)
- Renal failure
- Endocrine disorders (e.g., thyroid disease, diabetes)
- Malignancies
- Medication side effects or polypharmacy
The Role of AFTT in Medical Coding (ICD-10)
The ICD-10-CM code for adult failure to thrive is R62.7. This code falls under the broader category of "Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified" (R00-R99). Its location within this category is a key reason for its limited use as a primary diagnosis. ICD-10 coding guidelines specify that symptom codes should not be used as the primary diagnosis when a more specific, definitive diagnosis has been established.
Medical coders are instructed to identify and code the underlying condition first. R62.7 is only appropriate as the principal diagnosis when a comprehensive medical evaluation has been performed and no single dominant, treatable underlying cause can be identified, indicating a truly multifactorial decline.
Key ICD-10 Code Guidelines
- R62.7 (Adult failure to thrive): Use when decline is multifactorial and no dominant underlying cause is identified.
- E46 (Unspecified protein-energy malnutrition): Use when lab results confirm malnutrition.
- R64 (Cachexia): Use when cachexia is due to a specific condition like cancer.
AFTT and Hospice Care
The most stringent limitations on using AFTT as a primary diagnosis are found in hospice care billing. Federal guidelines from the Centers for Medicare & Medicaid Services (CMS) explicitly state that debility, adult failure to thrive (R62.7), and other nonspecific symptom codes cannot be used as the principal diagnosis on a hospice claim.
This policy exists to ensure that hospice patients are admitted based on a specific, terminal illness with a prognosis of six months or less, rather than on a vague, symptom-based diagnosis. While AFTT cannot be the principal diagnosis, the syndrome can be used as a secondary or additional diagnosis to help paint a more complete clinical picture of the patient's condition. The principal diagnosis on a hospice claim must be the terminal illness that is most contributory to the patient's prognosis, such as advanced cancer, heart failure, or a progressive neurological disorder.
Comparison Table: Principal Diagnosis Use
| Context | Can AFTT be a Primary Diagnosis? | Guidelines | Impact of Incorrect Coding |
|---|---|---|---|
| Acute Care (Hospital Admission) | No, it is strongly discouraged. | Use specific symptoms (e.g., anorexia, weakness) as working diagnoses while investigating. Search for an underlying acute medical issue. | Delays accurate diagnosis, appropriate treatment, and may lead to longer hospital stays and potentially harm. |
| Medical Coding (General) | Yes, but only in specific, limited circumstances. | Code R62.7 as the principal diagnosis only when no other single, definitive underlying cause can be identified after a comprehensive workup. | Higher risk of claim denials and audits if a more specific condition is documented but not coded as primary. |
| Hospice Billing (CMS) | No, it is prohibited as a principal diagnosis. | The principal diagnosis must be the terminal illness most contributory to the patient's prognosis. AFTT can be listed as a secondary diagnosis. | Results in claim denials and prohibits Medicare payment for the claim until a more definitive terminal diagnosis is provided. |
Conclusion
In most clinical contexts, adult failure to thrive is best understood as a syndrome or a set of symptoms rather than a primary disease process. While it serves as an important clinical red flag indicating multifactorial decline in a patient's health, particularly among the elderly, its use as a principal diagnosis is limited and often discouraged. For routine acute care, it can delay finding a treatable cause and implementing appropriate interventions. In medical coding, particularly for hospice claims under CMS rules, AFTT (R62.7) is explicitly disallowed as the principal diagnosis and can lead to claim denials. The most effective approach for healthcare providers is to conduct a thorough investigation to identify and address the specific underlying medical and psychosocial factors contributing to the patient's decline. When no dominant condition is found, careful documentation can allow for the use of the ICD-10 code R62.7, but this is a specific, last-resort scenario.
