MDS Alert

Question: A 74-year-old resident is complaining to aides that she is experiencing difficulty sleeping, nervousness, gastrointestinal (GI) problems, rapid breathing, mild depression, and heart palpitations. A physician administered a Patient Health Questionnaire for Depression and Anxiety (PHQ-9) and a Generalized Anxiety Disorder Test (GAD-7) to determine the resident’s condition. After scoring the test, the physician documented a diagnosis of anxiety with depression. What ICD-10-CM codes are appropriate for this encounter?

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Answer: Per ICD-10 guideline B.6, “signs and symptoms that may not be associated routinely with a disease process should be coded when present.” Consequently, in this case, since the physician has made a definitive determination of what the resident’s problem is, code only the diagnosis and not the symptoms.

The most difficult part of this case study is assigning the specific diagnosis code for anxiety with depression. If the depression is mild or not persistent, report F41.8 (Other specified anxiety disorders). The code includes mixed anxiety and depressive disorder, as it lists two similar-sounding synonyms: “Mixed anxiety and depressive disorder” and “Anxiety depression (mild or not persistent).”

However, if the physician documents that the resident has a major depressive disorder, then you would look at F32.- (Major depressive disorder, single episode). Only code this if there has been no previous major depressive episode, and list the anxiety separately under F41.- (Other anxiety disorders), excluding F41.8 as the depression is not determined to be mild. If the resident has a major depressive disorder that’s recurrent, you should look to F33.- (Major depressive disorder, recurrent).

Important:  Because one of the symptoms is GI problems, the physician may well perform additional lab tests to rule out a physical problem. You could also report that diagnosis, assuming a physical problem was found, and link it to any lab or diagnostic tests performed.

In that case, you would report the appropriate ICD-10 code for the identified GI problem or K92.9 (Disease of digestive system, unspecified) if a more specific diagnosis was not available, depending on the results of any tests the resident’s physician ordered. But you would not report any of the other signs and symptoms reported in the physician’s notes, as they are all common to the diagnosis of anxiety with depression.