Coding corner: importance of properly documenting major depressive disorder

Also known as clinical, unipolar or recurrent depression, major depressive disorder is defined as a mood disorder having a clinical course involving one or more episodes of serious psychological depression lasting two or more weeks per episode with no intervening episodes of mania.

The additional characteristics used to diagnose this condition should always be documented in the medical record in order to substantiate the diagnosis for coding, billing and reimbursement purposes. These characteristics should always detail the most recent episode that the patient has experienced. At least five of the nine symptoms listed need to be present almost daily for the patient to be diagnosed with major depressive disorder, including at least one of the first two listed at right.

Major depressive disorder is assigned to ICD-9 subcategories 296.2 and 296.3, depending on whether the condition is a single episode (296.2) or a recurrent episode (296.3). The fifth digit subclassifications are used to specify the severity of the condition and to identify the presence of related psychotic features, if applicable. A fifth-digit is always necessary when coding major depressive disorder. For more details, see information about fifth-digit classifications at right.

The terms for the fifth-digit subclassifications of major depressive disorder are used in conjunction with specific diagnostic criteria listed below. Refrain from coding to a specific severity level if that level isn’t stated in the medical record, even if documentation of the clinical requirements for that level of severity are noted in the exam.

• Unspecified: When the information in the medical record is insufficient to assign a more specific code.
• Mild: The patient experiences at least five of the symptoms needed for a diagnosis of major depressive disorder, which also pose a mild overall functional impairment.
• Moderate: The patient experiences seven to eight of the symptoms, or the symptoms pose a moderate overall functional impairment.
• Severe without psychotic features: The patient experiences most or all of the symptoms, or the symptoms they do experience pose a severe functional impairment but present without any psychotic features.
• Severe with psychotic features: The patient experiences most or all of the symptoms, the symptoms pose a severe functional impairment or the symptoms present with delusions or hallucinations.
• In remission: The patient previously had two or more episodes but has been free from symptoms for at least two months.
• In partial remission: Either some symptoms can still be present, but the full criteria are no longer met, or there are no longer any significant symptoms of an episode, but the patient hasn’t been in remission for at least two months.

ICD-10 transition
There are few changes for coding MDD with the transition to ICD-10. The 14 codes that were used for ICD-9 will transition to 15 codes for ICD-10, including a code for MDD, recurrent episode in unspecified remission. This will require physicians to document whether the remission status is partial or complete in order to avoid use of an unspecified code choice.

The most significant change for ICD-10 is that documentation stating “depression,” with nothing further documented, will now be coded as major depression, ICD-10 code F32.0. With ICD-9, it was coded as depression NOS code 311.

Here are the ICD-10 code choices for major depressive disorder:

• F32.0 - MDD, single episode, mild
• F32.1 - MDD, single episode, moderate
• F32.2 - MDD, single episode, severe without psychotic features
• F32.3 - MDD, single episode, severe with psychotic features
• F32.4 - MDD, single episode, in partial remission
• F32.5 - MDD, single episode, in full remission
• F32.9 - MDD, single episode, unspecified
• F33.0 - MDD, recurrent episode, mild
• F33.1 - MDD, recurrent episode, moderate
• F33.2 - MDD, recurrent episode, severe without psychotic features
• F33.3 - MDD, recurrent episode, severe with psychotic features
• F33.40 - MDD, recurrent episode, in remission, unspecified
• F33.41 - MDD, recurrent episode, in partial remission
• F33.42 - MDD, recurrent episode, in full remission
• F33.9 - MDD, recurrent episode, unspecified

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.