Internal Medicine Coding Alert

Question: What ICD-9 codes should I use when a patient exhibits signs of depression, but the physician does not diagnose depression? The physician recently performed a level-two evaluation and management service on a new patient whose husband just died. She had insomnia and was not eating much, but the physician did not think the patient met the parameters for depressive disorder.

Minnesota Subscriber

Answer: In the absence of a definitive depression diagnosis from the doctor, you'll want the diagnosis coding to reflect the patient's signs and symptoms. On your claim,

• report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; straightforward medical decision-making) for the E/M service.

• link 307.42 (Persistent disorder of initiating or maintaining sleep) to 99202 to represent the patient's insomnia.

• link 783.0 (Anorexia) to 99202 to represent the patient's appetite loss.