Documentation and Coding: Major Depressive Disorder
A quick reference guide to assist with accurate, complete documentation and coding that reflects the true nature of a patient’s current health status at the highest level of specificity.
Per ICD-10 official guidelines for reporting and coding “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”
DSM-5 Criteria for Major Depressive Disorder: The individual must be experiencing five or more symptoms during the same 2-week period and at least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure.
- Decreased interest of pleasure in most activities, most of each day
- Depressed mood or irritable most of the day
- Fatigue or loss of energy
- Significant weight change (5 percent) or change in appetite
- Change in sleep: Insomnia or hypersomnia
- Change in activity: Psychomotor agitation or retardation
- Guilt/worthlessness: feeling of worthlessness or excessive inappropriate guilt
- Concentration: diminished ability to think or concentrate, or more indecisiveness
- Suicidality: thoughts of death or suicide, or has suicide plan
Documentation and Coding Guidance
Documentation needs to be clear and detailed using the following terms to allow accurate ICD10 code selection
Specificity:
-
Episode Type: Single or recurrent episode
-
Current state:
- New onset
- Partial remission: patient without any significant symptoms for less than two months timeframe
- Full remission: patient has no significant depressive symptoms present during the last two months or more
-
Severity: mild, moderate, severe, severe with psychotic features
Treatment: Document treatment (medication, psychotherapy, or a combination of both) and current response to treatment.
| ICD 10 Code | Description: Major Depressive Disorder (MDD), single episode | ICD 10 Code | Description: Major Depressive Disorder (MDD), recurrent |
| F32.0 | “ “, mild | F33.0 | “ “, mild |
| F32.1 | “ “, moderate | F33.1 | “ “, moderate |
| F32.2 | “ “, severe without psychotic features | F33.2 | “ “, severe without psychotic features |
| F32.3 | “ “, severe with psychotic features | F33.3 | “ “, severe with psychotic features |
| F32.4 | “ “, in partial remission | F33.40 | “ “, in remission, unspecified |
| F32.5 | “ “, in full remission | F33.41 | “ “, in remission, in partial remission |
| F32.9 | “ “, unspecified | F33.42 | “ “, in remission, in full remission |
| F33.9 | “ “, unspecified |
Other Depression ICD10 codes
- F32A = Depression, unspecified
- F32.81 = Premenstrual dysphoric disorder
- F32.89 = Other specified depressive episodes
- F33.8 = Other recurrent depressive disorders
- F34.9 = Persistent mood (affective) disorder, unspecified
References
www.psychiatry.org - American Psychiatric Association – Depression
Optum 360 – Encoder Pro – Major Depression
Diagnostic and Statistical Manual 5 (DSM-5)