Title

Documentation and Coding: Major Depressive Disorder

Publication Date:

2022-10-18

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	Change in activity: Psychomotor agitation or retardation
Depressed mood or irritable most of the day	Guilt/worthlessness: feeling of worthlessness or excessive inappropriate guilt
Fatigue or loss of energy	Concentration: diminished ability to think or concentrate, or more indecisiveness
Significant weight change (5%) or change in appetite	Suicidality: thoughts of death or suicide, or has suicide plan
Change in sleep: Insomnia or hypersomnia

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	ICD 10 Code	Description
	Major Depressive Disorder (MDD), single episode		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)

Title

Documentation and Coding: Major Depressive Disorder

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