Coding corner: Proper coding for major depressive disorder

Major depressive disorder, also known as clinical depression, is a common but serious mood disorder. It affects how one feels, thinks and behaves. A person having trouble doing activities nearly every day for at least two weeks may be suffering from this disorder. Signs and symptoms of MDD, including details of the most recent episode, should always be documented in the patient’s medical record to substantiate the diagnosis.

Example of symptoms of an MDD episode

• Depressed or irritable mood
• Decreased interest or pleasure
• Change in activity
• Fatigue or loss of energy
• Diminished concentration, memory or ability to make decisions
• Guilt or sense of worthlessness
• Significant change in weight or appetite
• Change in sleep patterns
• Restlessness, inability to sit still
• Aches or pains, headaches, cramps or digestive problems without a clear physical cause and don’t subside with treatment
• Thoughts of death, self-harm or suicide

Major depressive disorder is assigned to ICD-10-CM categories F32 Major depressive disorder, single episode and F33 Major depressive disorder, recurrent. Categories F32 and F33 include fourth characters, and sometimes fifth characters, to capture information about the severity of the major depressive disorder. The severity can be defined as:

• 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 at least seven to eight 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 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.

If information isn’t present in the medical record that identifies the severity of the disorder, the ICD-10-CM classification includes “unspecified” diagnosis codes. Unspecified codes are used when the information in the medical record is insufficient to assign a more specific code.

Caution should be taken to only code the medical condition that is stated in the medical record, even when documentation of the clinical requirements for a different level of severity is noted in the medical record. For example, if “depression” is documented in the patient’s medical record but the medical record also states, “Exhibits sadness and is withdrawing from friends,” only the depression can be coded. The diagnosis is what is coded. Additional clinical documentation would be considered supporting documentation for the depression. 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.

Listed below are all the subcategory choices for MDD.

ICD-10 code choices

• F32.0 Major depressive disorder, single episode, mild
• F32.1 Major depressive disorder, single episode, moderate
• F32.2 Major depressive disorder, single episode, severe without psychotic features
• F32.3 Major depressive disorder, single episode, severe with psychotic features
• F32.4 Major depressive disorder, single episode, in partial remission
• F32.5 Major depressive disorder, single episode, in full remission
• F32.9 Major depressive disorder, single episode, unspecified
• F33.0 Major depressive disorder, recurrent, mild
• F33.1 Major depressive disorder, recurrent, moderate
• F33.2 Major depressive disorder, recurrent, severe without psychotic features
• F33.3 Major depressive disorder, recurrent, severe with psychotic features
• F33.4 Major depressive disorder, recurrent, in remission
• F33.9 Major depressive disorder, recurrent, unspecified

Note: Medical record documentation that simply states “depression” and has no further supporting documentation will index to subcategory F32.9, Major depressive disorder, single episode, unspecified per the ICD-10-CM Alphabetic Index.

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 all applicable state and federal laws and regulations. Also, ICD-10-CM diagnosis codes and ICD-10-CM Official Guidelines for Coding and Reporting are subject to change. It’s the responsibility of the provider to ensure that current ICD-10-CM diagnosis codes and the current ICD-10-CM Official Coding Guidelines for Coding and Reporting are reviewed prior to the submission of claims.