Internal Medicine Coding Alert

Hint: Use different code sets when the diagnosis is recurrent episodes of MDD.

When your internist diagnoses single episodes of major depressive disorder, you’ll report it in ICD-10 in a similar way to what you did in ICD-9. You’ll have to base your code selection depending on the severity of the symptoms, presence of psychotic behavior, and knowing whether or not the condition is in remission.

ICD-9: When your clinician diagnoses a single episode of major depressive syndrome, you’ll have to base your reporting of the diagnosis on the severity of symptoms. You start out with 296.2 (Major depressive disorder, single episode). This ICD-9 code expands further based on severity of the condition, the presence or absence of psychotic behavior, and whether or not it is in remission.

Depending on the severity of symptoms, 296.2 expands into seven codes to help you aptly report a diagnosis of single episode of major depressive disorder; those codes include the following:

• 296.20 -- Major depressive disorder, single episode, unspecified 
• 296.21 -- Major depressive disorder, single episode, mild 
• 296.22 -- Major depressive disorder, single episode, moderate 
• 296.23 -- Major depressive disorder, single episode, severe, without mention of psychotic behavior
• 296.24 -- Major depressive disorder, single episode, severe, specified as with psychotic behavior
• 296.25 -- Major depressive disorder, single episode, in partial or unspecified remission
• 296.26 -- Major depressive disorder, single episode, in full remission.

Caveat: You need to take care that you do not report 296.2x when your clinician’s diagnosis is recurrent episodes of major depressive disorder. This has to be reported with 296.3x, which again expands into similar code choices depending on the severity of the condition, the presence or absence of psychotic behavior, and whether or not it is in remission. Also, you cannot use 296.2x if your clinician’s diagnosis is depression NOS (311); reactive depression (neurotic) (300.4); depressive type psychosis (298.0); or if the major depressive disorder is a circular type and the previous attack was of a manic type (296.5) (i.e., the patient suffers from Bipolar 1 disorder).

ICD-10: When you switch over to using ICD-10 codes for reporting your clinician’s diagnoses, a diagnosis of a single episode of major depressive disorder will crosswalk to F32 (Major depressive disorder, single episode). As in ICD-9, F32also expands to several code choices based on severity of the symptoms, the presence and absence of psychotic behavior, and whether or not it is in remission:

• F32.0 -- Major depressive disorder, single episode, mild
• F32.1 -- Major depressive disorder, single episode, moderate
• F32.2 -- Major depressive disorder, single episode, severe without psychotic features
• F32.3 -- Major depressive disorder, single episode, severe with psychotic features
• F32.4 -- Major depressive disorder, single episode, in partial remission
• F32.5 – Major depressive disorder, single episode, in full remission
• F32.8 – Other depressive disorders
• F32.9 -- Major depressive disorder, single episode, unspecified.

Check on These Basics Briefly

Documentation spotlight: Your provider will arrive at a diagnosis of a single episode of major depressive disorder based on a complete history and a complete evaluation of the patient. Your physician will perform a complete mental status examination, a complete psychiatric and medical history of the patient and family, and a review of systems.

Some of the findings that your clinician would most likely record in a patient with major depressive disorder will include depression of mood, irritability, reduced interest in activities, sleep disturbances, reduced energy levels, weight changes, decreased concentration, feeling worthless, and suicidal tendencies.

When performing a physical and mental status examination, your clinician might note that the patient appears normal and well groomed, although this might not be the case in a patient suffering from a severe degree of major depressive disorder.

Tests: Although there are no specific diagnostic tests available for your clinician to clinch a diagnosis of major depressive disorder, he might still perform or order some tests to rule out other conditions that might present with similar symptoms and findings.  

Some of the tests that your clinician is more likely to order will include complete blood count (CBC), liver function tests, kidney function tests, arterial blood gases (ABG), and tests to check blood alcohol levels and to check for other substance abuse.

Apart from these tests, your clinician will look at performing some screening tests, such as Patient Health Questionnaire-9 (PHQ-9), Zung Self-Rating Depression Scale, or the Beck’s Depression inventory. These tests will involve the patient answering some questionnaires with the help of which your clinician might diagnose major depressive disorder. He might also look at using other rating scales, such as the Hamilton depression rating scale (HDRS), to assess the patient and to diagnose the severity of the depressive disorder.

The immediate care planning will include assessment of the patient for suicidal or homicidal tendencies that might require rapid attention and crisis psychotherapy. At later dates, your clinician might include psychotherapy and group therapy. He might also opt for concurrent medication with antidepressants. Some patients have also benefited from other forms of therapy, such as electroconvulsive therapy, transcranial magnetic stimulation, and phototherapy.

Example: Your provider evaluates an established 35-year-old female patient for complaints of depressed mood and problems with concentration. She says that she has been experiencing these symptoms ever since her husband ran away with her best friend about three months back, although the symptoms seemed to have increased in the past month or so.

Your clinician notes that the patient had a normal appearance and grooming. Upon questioning, the patient appeared to get irritable for no reason and sometimes appeared listless and tired. She also told that she had trouble sleeping at night. Further, she complained that her sleep disturbances and concentration difficulties were affecting her ability at work and that she was facing the likelihood of getting fired from her job.

Your clinician suspects a diagnosis of major depression. To rule out other conditions, your clinician ordered blood tests, liver function tests, and tests for alcohol and substance abuse, and they all returned normal. He also subjected the patient to screening questionnaires, like the PHQ-9 and HDRS. 

Based on the results of these evaluation screening questionnaires and from history and present signs and symptoms, your clinician diagnosed the patient with moderate major depressive disorder, single episode.

What to report: You will report the evaluation that your physician provided with an appropriate established patient E/M code such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient …). You report the diagnosis with 296.22 if you are using ICD-9 codes or report F32.1 when reporting the diagnosis with ICD-10 codes.