Documenting and coding: Depression vs. Major depression

Documenting and coding: Depression vs. Major depression

  • 30 Mar 1
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When documenting depression, it is important to document completely and accurately in order for the most appropriate and specific code to be assigned.   The correct diagnosis and ICD-9 code may be the difference between a diagnosis that maps to an HCC and one that does not.  For example, ICD-9 code 311 (depressive disorder, NEC) does not map to an HCC, but 296.XX (major depression) maps to HCC 58.

There are not DSM IV criteria for “depression” and “major” depression; only criteria for Major depression.   If the criteria listed in the DSM IV is met, documentation should reflect major depression.  Major depressive disorders are classified in ICD-9-CM as episodic mood disorders with category 296.  The fourth digit, 296.2x and 296.3x, is coded to define a single or recurrent episode respectively.  When applicable, designate major depression as recurrent and code 296.30, if the condition has known episodes with complete recovery between.  If a provider documents only major depression, the correct code, per ICD-9 guidelines, is 296.20.

The fifth digit is coded to define the severity of the current depressive episode:  0 – unspecified; 1 – mild; 2 – moderate; 3 – severe, without mention of psychotic behavior; 4 – severe, specified as with psychotic behavior.  For those who are no longer exhibiting signs and symptoms of depression but are being treated for it, continue to document major depression, but note the level of remission (partial or complete).  If the criteria are not currently met for major depressive episode, the fifth digit indicates the current clinical status: 5 – in partial or unspecified remission and 6 – in full remission

For new participants with a previous diagnosis of major depression or depression and are currently on treatment, further investigation may be necessary.  A review of past medical records or questioning the participant and/or family may give good insight on the diagnosis.

“Depressive disorder” or “Depression” have no diagnostic criteria in DSM and represent an ambiguous condition with a mental state of depressed mood characterized by feelings of sadness, despair and discouragement.  It is an unpleasant, but not necessarily irrational or pathological, mood state characterized by sadness, despair, or discouragement; “the blues”; and may involve low self-esteem, social withdrawal, and somatic symptoms such as eating and sleep disturbance.  This is a mild depression that is not considered clinical depression and will be coded as 311.  For clinical depression, use major depression or MDD as the terminology and code as described above.

For more information about documenting and coding for depression, please contact us.