Internal Medicine Coding Alert

Hint: Identify psychotic symptoms in severe type of MDD.

When your physician’s diagnosis is recurrent episodes of major depressive disorder, you’ll report it the same way as 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 recurrent episodes of major depressive syndrome, you’ll have to base your reporting of the diagnosis on the severity of symptoms. You start out with 296.3 (Major depressive disorder, recurrent episode). This ICD-9 code expands further based on severity of the condition and on the presence or absence of psychotic behavior.

The seven code choices to which 296.3 expands to help you aptly report a diagnosis of recurrent episodes of major depressive disorder include the following:

• 296.30 -- Major depressive disorder, recurrent episode, unspecified 
• 296.31 -- Major depressive disorder, recurrent episode, mild 
• 296.32 -- Major depressive disorder, recurrent episode, moderate 
• 296.33 -- Major depressive disorder, recurrent episode, severe, without mention of psychotic behavior
• 296.34 -- Major depressive disorder, recurrent episode, severe, specified as with psychotic behavior
• 296.35 -- Major depressive disorder, recurrent episode, in partial or unspecified remission
• 296.36 -- Major depressive disorder, recurrent episode, in full remission

Caveat: You need to take care that you do not report 296.3x when your clinician’s diagnosis is major depressive disorder, single episode. This has to be reported with 296.2x, 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 296.3x 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 recurrent episodes of major depressive disorder will crosswalk to F33 (Major depressive disorder, recurrent). As in ICD-9, F33 further expands to the following code choices based on severity of the symptoms and the presence or absence of psychotic behavior:

• F33.0 -- Major depressive disorder, recurrent, mild
• F33.1 -- Major depressive disorder, recurrent, moderate
• F33.2 -- Major depressive disorder, recurrent, severe without psychotic features
• F33.3 -- Major depressive disorder, recurrent, severe with psychotic symptoms
• F33.4 -- Major depressive disorder, recurrent, in remission
• F33.8 – Other recurrent depressive disorders
• F33.9 -- Major depressive disorder, recurrent, unspecified

Reminder: If your clinician identifies the condition to be in remission, you’ll need to identify whether it is in partial remission or full remission as F33.4 further expands into three code choices depending on this:

• F33.40 -- Major depressive disorder, recurrent, in remission, unspecified
• F33.41 -- Major depressive disorder, recurrent, in partial remission
• F33.42 -- Major depressive disorder, recurrent, in full remission

Check on These Basics Briefly

Documentation spotlight: Your internal medicine provider will arrive at a diagnosis of recurrent major depressive disorder based on a complete history and a complete evaluation of the patient. 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.

Example: Your physician reviews a 45-year-old female patient for recurrent symptoms of depression. The patient had a previous history of major depression about five years back. She was treated with SSRI antidepressants at that time and had been taking the medication for sometime till her symptoms disappeared. Once she had begun feeling fine, she had discontinued her medication and had been free of all symptoms of depression till it had begun to recur from the past two months.

Your clinician notes 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. The patient also informed that she had lost her job recently and that loss began to make her feel worthless and she began to lose interest in all day-to-day activities. She also told that she had trouble sleeping at night.

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 the lab tests and screening questionnaires and from the patient’s history and present signs and symptoms, your clinician diagnosed the patient with moderate recurrent major depressive disorder.

What to report: You will report the diagnostic evaluation of the patient with 90792 (Psychiatric diagnostic evaluation with medical services) if the service fits that description, or an appropriate evaluation and management code, such as 99214 (Office or other outpatient visit for the evaluation and management of an established patient…). You report the diagnosis with 296.32 if you are using ICD-9 codes or report F33.1 when reporting the diagnosis with ICD-10 codes.