Blue Review
A Provider Publication
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May 2021

Documentation and Coding

Major Depressive Disorder

Depression is one of the most common mental disorders. It carries a high cost in terms of relationship problems, family suffering and lost work productivity, according to the American Psychiatry Association Leaving Site Icon. Accurately and completely documenting and coding Major Depressive Disorder (MDD) can help our members access needed resources. Below is information from the ICD-10-CM Official Guidelines for Coding and Reporting Leaving Site Icon.

Sample ICD-10-CM Codes for Single MDD Episode
F33.0 Single episode, mild
F33.1 Single episode, moderate
F33.2 Single episode, severe without psychotic features
F33.3 Single episode, severe with psychotic feature
F33.4x Single episode, in partial remission
F33.8 Single episode, in full remission
F33.9 Other depressive disorders
 
Sample ICD-10-CM Codes for Recurrent MDD Episodes
F32.0 Recurrent, mild
F32.1 Recurrent, moderate
F32.2 Recurrent, severe without psychotic features
F32.3 Recurrent, severe with psychotic symptoms
F32.4 Recurrent, in remission
F32.8x Other recurrent depressive disorders
F32.9 Recurrent, unspecified

Coding for MDD

When coding and documenting for MDD, it’s critical to capture the episode and severity with the most accurate diagnosis codes.

Documentation should include:

  • Episode: single or recurrent
  • Severity: mild, moderate, severe without psychotic features or severe with psychotic features
  • Clinical status of the current episode: in partial or full remission

The fourth and fifth characters in the ICD-10-CM codes capture the severity and clinical status of the episode.

F32.9 MDD, single episode, unspecified, is equivalent to Depression Not Otherwise Specified (NOS), Depressive Disorder NOS and Major Depression NOS. This code should rarely be used and only when nothing else, such as the severity or episode, is known about the disorder.

Best Practices

  • Include patient demographics, such as name, date of birth and date of service in all progress notes.
  • Document legibly, clearly and concisely.
  • Ensure a credentialed provider signs and dates all documents.
  • Document each diagnosis as having been monitored, evaluated, assessed and/or treated on the date of service.
  • Note complications with an appropriate treatment plan.
  • Take advantage of the Annual Health Assessment (AHA) or other yearly preventative exam as an opportunity to capture all conditions impacting member care.

For more details, see: