Coding corner: Proper coding for major depressive disorder

Major depressive disorder is also known as clinical, unipolar or recurrent depression. It’s 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.

You should always document the symptoms of MDD in the patient’s medical record to substantiate the diagnosis. Be sure to provide details of the most recent episode the patient experienced.

According to the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), at least five of the nine symptoms listed at right need to be present on a regular basis during the same two-week period for the patient to be diagnosed with MDD. At least one of the symptoms must either be a depressed mood or loss of interest.

MDD is assigned to ICD-10 subcategories, depending on whether the condition is a single episode (F32.–) or a recurrent episode (F33.–). A fourth character is always necessary when coding MDD. The fourth-digit subclassifications specify the severity of the condition and identify the presence of related psychotic features, if applicable. A fifth character is only necessary when using subcategory F33.4– (major depressive disorder, recurrent, in remission) to specify if the patient is in partial, complete or an unspecified level of remission.

The terms utilized for the fourth- and fifth-digit subclassifications of MDD are used in conjunction with the specific diagnostic criteria listed below. The list details the level of severity along with the requirements needed to diagnose the severity.

• Unspecified: This term is used 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 MDD, which also pose a mild overall functional impairment.
• Moderate: The patient experiences seven to eight symptoms, or the symptoms he or she suffers from pose a moderate overall functional impairment.
• Severe without psychotic features: The patient experiences most or all of the symptoms, or the symptoms he or she experiences pose a severe functional impairment, but the patient presents without any psychotic features.
• Severe with psychotic features: The patient experiences most or all of the symptoms, or the symptoms he or she experiences pose a severe functional impairment and the patient presents with psychotic features.
• In full remission: The patient previously had two or more episodes but has been free from symptoms for at least two months.
• In partial remission: Some symptoms may 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 two months or longer.

Caution should be taken when coding to a specific severity level without that level being stated in the medical record, even if documentation of the clinical requirements for that level of severity are noted in the medical record. Providers should clearly state the level of severity of the depression and correlate this with supporting documentation, such as current prescribed medications, a PHQ-9 or another standardized assessment.

The major difference between ICD-9 and ICD-10 coding for depression is that medical record documentation that simply states “depression” and has no further supporting documentation will now index to “major depression, single episode, unspecified (F32.9).” Following are all the code choices for MDD.

ICD-10 code choices

• 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 herein 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 all applicable state and federal laws and regulations.