Correct ICD-10 Documentation: MDD

Correct ICD-10 Documentation: MDD

  • 11 Oct Off
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by Tiffany Brookshire, RN, BSN, CRN-C

The implementation of ICD-10 has increased the specificity for many, if not all, disease processes. One such condition is Major Depressive Disorder, a commonly diagnosed condition in the PACE participant population. The correct documentation of MDD will result in a more specific and risk adjusted code, while incomplete documentation will result in an unspecified code that does not map to an HCC.

Tiffany Brookshire, RN, BSN, CRN-C Risk Adjustment & Coding Specialist

Tiffany Brookshire, RN, BSN, CRN-C
Risk Adjustment & Coding Specialist

Documentation of Major Depressive Disorder should include severity: mild, moderate, or severe as well as episode status: single or recurrent. Additionally, documentation of MDD should include if the participant has reached full or partial remission, if remission has been reached. Finally, it is important to document if the participant has psychotic features with MDD, as well. Including all of these elements will result in the most specific code available, as well as ensuring that the condition will risk adjust.

Examples of documentation of MDD:

  • Mrs. Jones has severe major depression disorder, single episode with psychotic features without having reached remission. She is being treated with antidepressants and antipsychotics and is receiving cognitive behavior therapy at the center: F32.3.
  • Mr. Smith has mild major depression, recurrent episode, without remission, without psychotic features. He is being treated with Paxil and sees a licensed therapist at the center: F33.0
  • Mrs. Campbell is being seen today for recurrent major depressive disorder that is in partial remission. She continues her medication and reports an improved outlook on life. She will continue to receive cognitive behavior therapy at the center: F33.41.

As evidenced by the above examples, the specificity for Major Depressive Disorder documentation has increased considerably from ICD-9 documentation requirements. However, it is best practice now to include all pertinent information relating to the condition to ensure that the most accurate code can be applied, the condition will risk adjust, and the documentation will not have to be queried for specificity.