Coding corner: 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. Always document signs and symptoms of MDD in the patient’s medical record to support the diagnosis. Include details of the most recent episode.

Examples 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 that don’t subside with treatment
• Thoughts of death, self-harm or suicide

MDD is assigned to the following ICD-10-CM categories:

• F32 — Major depressive disorder, single episode
• F33 — Major depressive disorder, recurrent

Categories F32 and F33 include fourth characters, and sometimes fifth characters, to capture information about the severity of the MDD. The severity can be defined as:

• Mild: The patient experiences at least five of the symptoms needed for a diagnosis, 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 the symptoms, or the symptoms pose a severe functional impairment, but the patient presents without any psychotic features.
• Severe with psychotic features: The patient experiences most or all the symptoms, or the symptoms 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’s 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 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 Patient Health Questionnaire-9, or PHQ-9, or another standardized assessment.

ICD-10-CM code subcategory choices for MDD:

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.

2018 Updates ICD- 10-CM Official Guidelines for Coding and Reporting
(Updates are in bold)

Chapter 5: Mental, Behavioral and Neurodevelopmental Disorders (F01 – F99)

b. Mental and behavioral disorders due to psychoactive substance use

1) In Remission
Selection of codes for “in remission” for categories F10-F19, Mental and behavioral disorders due to psychoactive substance use (categories F10-F19 with -11, -.21) requires the provider’s clinical judgment. The appropriate codes for “in remission” are assigned only on the basis of provider documentation (as defined in the Official Guidelines for Coding and Reporting), unless otherwise instructed by the classification.

Mild substance use disorders in early or sustained remission are classified to the appropriate codes for substance abuse in remission, and moderate or severe substance use disorders in early or sustained remission are classified to the appropriate codes for substance dependence in remission.

3) Psychoactive Substance Use Disorders
As with all other diagnoses, codes for psychoactive substance use disorders (F10.9-, F11.9-, F12.9-, F13.9-, F14.9-, F15.9-, F16.9-) should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis (see Section III, Reporting Additional Diagnoses). Use these codes only when the psychoactive substance use is associated with a physical, mental or behavioral disorder, and such a relationship is documented by the provider.