30 Aug Off
Depression is a growing issue in the United States. As of 2019, the National Institute of Mental Health (NIMH) estimated 17.3 million adults as having at least one major depressive episode*. The National PACE Association (NPA) also lists major depressive disorder as one of the top five chronic conditions among PACE participants**. As is the case with other diagnoses, accurately and specifically documenting depression is vital to the patient, the provider, and the coder.
Detailed provider documentation is the foundation on which the coder builds ICD-10-CM detail as it can differentiate a prescription drug hierarchical condition category (RxHCC) from a hierarchical condition category (HCC). A provider’s ability to clinically document more descriptively can capture a greater number of HCCs, which helps organizations remain compliant and optimize revenue.
One single episode of major depression corresponds with RxHCC code F32.9 Major depressive disorder, single episode, unspecified. Based on Capstone’s expertise, when providers diagnose major depression, it rarely means the patient had one single episode of major depression. To accurately depict major depression beyond one single episode and capture an HCC, the provider must add more specificity to the diagnosis. It is also important to remember that all documentation must be in the face-to-face visit form to be coded.
There are three opportunities to capture major depression HCC058 Major Depressive, Bipolar, and Paranoid Disorders:
- If the provider documents major depression, recurrent, it will index to diagnosis code F33.9 Major depressive disorder, recurrent, unspecified and capture HCC058 Major Depressive, Bipolar, and Paranoid Disorders.
- If the provider documents major depression, moderate, it will index to diagnosis code F32.1 Major depressive disorder, single episode, moderate and capture HCC058 Major Depressive, Bipolar, and Paranoid Disorders.
- Even when major depression is in partial or full remission, if the provider documents major depression, in full remission, it will index to a diagnosis code F32.5, Major depressive disorder, single episode, in full remission and capture HCC058 Major Depressive, Bipolar, and Paranoid Disorders.
Understanding how to completely and accurately document major depression not only allows the provider to tell a more accurate story of the patient’s medical picture, but it also allows the coder to select the code more easily with the highest specificity.
Erin E. Morgan, RHIT, CRC
Risk Adjustment & Coding Specialist
*National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/major-depression. Accessed 7 July 2021.
**National PACE Association. https://www.npaonline.org/sites/default/files/images/infographic_images/pace_infographic_update_side1_may2021.pdf. Accessed 14 July 2021.