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Types of Depressive Disorder For Coding

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Types of Depressive Disorder For Coding

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justarandomemail013
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Documenting and Coding Major

Depressive Disorders
Single
Code Description Recurrent DSM-5 Notes
Episode
Major depressive disorder, F32.9* F33.9 Major depressive disorder is characterized by
unspecified discrete episodes of at least 2 weeks’ duration
(although most episodes last considerably
longer) involving changes in affect, cognition,
and neurovegetative functions and inter-episode
remissions. A diagnosis based on a single episode
is possible, although the disorder is a recurrent
one in the majority of cases. Careful consideration
is given to the delineation of normal sadness and
grief from a major depressive episode.

Major depressive disorder, F32.0 F33.0 Mild: Few, if any, symptoms in excess of those
mild required to make the diagnosis are present, the
intensity of the symptoms is distressing but
manageable, and the symptoms result in minor
impairment in social or occupational functioning.

Major depressive disorder, F32.1 F33.1 Moderate: The number of symptoms, intensity
moderate of symptoms, and/or functional impairment are
between those specified for “mild” and “severe.”

Major depressive disorder, F32.2 F33.2 Severe: The number of symptoms is substantially
severe without psychotic in excess of that required to make the diagnosis,
features the intensity of the symptoms is seriously
distressing and unmanageable, and the
symptoms markedly interfere with social and
occupational functioning.

Major depressive disorder, F32.3 F33.3 Delusions, psychosis, or hallucinations are


severe with psychotic features present at any time during the episode.

Major depressive disorder, N/A F33.40 Unspecified level of remission.


in remission, unspecified**

Major depressive disorder, F32.4 F33.41 Symptoms of the immediately previous major
in partial remission** depressive episode are present but full criteria
are not met, or there is a period lasting less than
2 months without any significant symptoms of a
major depressive episode following the end of
such an episode.

Major depressive disorder, F32.5 F33.42 During the past 2 months, no significant signs
in full remission** or symptoms of the disturbance were present.

Depression, unspecified. F32.A N/A N/A


(depression NOS and
depressive disorder NOS.)

*Attempt greater specificity if possible.


**Remission codes can be used when depression has improved
due to medication or treatment.
Depression Diagnostic Tools
and Documentation Best Practices:
✓ When documenting MDD, specify whether the depression is recurrent or a single episode.
✓ Document absence or presence of psychotic symptoms and/or features.
✓ Document whether the depression is in full or partial remission.
✓ Specify in documentation whether the depression is mild, moderate or severe. You may use
PHQ-9 scoring to stage depression as shown below:

Depression
PHQ-9 Score Proposed Treatment
Severity

0-4 None-minimal None.

5-9 Mild Watchful waiting; repeat PHQ-9 at follow-up.

10 - 14 Moderate Treatment plan, consider counseling, follow-up


and/or pharmacotherapy.

15 - 19 Moderately Active treatment with pharmacotherapy


Severe and/or psychotherapy.

20 - 27 Severe Immediate initiation of pharmocotherapy and, if severe


impairment or poor response to therapy, expedited
referral to a mental health specialist for psychotherapy
and/or collaborative management.

* From Kroenke K, Spitzer RL, Psychiatric Annals 2002;32:509-521

Sources
AAPC ICD-10 CM Expert 2021: An official Guide for Hospitals and Physicians.
Poe Bernard, S. (2020) Risk Adjustment Documentation and Coding, Second Edition. Chicago: American Medical Association
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing
Pfizer Corporation, www.PHQScreeners.com. PHQ-9 Instruction Manual. Accessed June 2021.

Please refer to official current year ICD-10 Guidelines for additional information.
This document is for educational purposes only and not meant to replace official guidelines.

PHRCHY21-depressdisordertipfl-1121

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