Documenting Major Depressive Disorder

Documenting Major Depressive Disorder

  • 18 Jul Off
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By Denise Wills, CPC-A

When documenting depression, accuracy is important in determining the most specific code. If incomplete documentation is received, it will result in an unspecified code selection, which does not map to an HCC. For example, ICD-10 code F32.9 (MDD, single episode, unspecified) does not map to an HCC, whereas F32.0 (MDD, single episode, mild) does.

The ICD-10 classification of Mental and Behavioral Disorders, developed in part by the American Psychiatric Association, classifies depression by code.  Documentation of Major Depressive Disorder should include:

  • The episode status – single episode or recurrent
  • The severity of depression – mild, moderate, or severe
  • If the depression is indicated as severe, it should be documented as “with” or “without psychotic features”
  • If the depression is in remission, documentation must indicate either partial or full remission.

Careful inclusion of these components will produce the most specific code possible.

The classification of “in remission” indicates that the patient has had two or more depressive episodes in the past, but is currently free from depressive symptoms.

A “recurrent” episode is characterized by repeated episodes, with one episode lasting at least two weeks. This is followed by complete remittance while off medical and behavioral therapies for at least two months, and then experiencing another episode.

The classification of “recurrent, in remission” indicates that the patient has had two or more depressive episodes in the past, but is currently free of depressive symptoms. The following is a list of symptoms for Major Depressive Disorder:

Denise Wills, CPC-A

  • Depressed mood most of the day, nearly every day, as indicated in the subjective report or in observation made by others
  • Markedly diminished interest in pleasure in all, or almost all, activities most of the day and nearly every day
  • Significant weight loss when not dieting or weight gain; for example, more than 5 percent of body weight in a month or changes in appetite nearly every day
  • Insomnia or hypersomnia nearly every day
  • Psychomotor agitation or retardation nearly every day
  • Fatigue or loss of energy nearly every day
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Diminished ability to think or concentrate, or indecisiveness nearly every day
  • Recurrent thoughts of death

It is always best practice to include all relative information for the condition you are documenting.