Pediatric Coding Alert

Quickly arrive at the correct code choice and stay ahead of the pandemic curve.

Has the pandemic increased the number of child and adolescent mental health encounters at your pediatric practice? Anecdotally, “we have seen a spike in mental health services rendered, diagnoses made, and requests for assistance to bill and code these services,” says Jan Blanchard, CPC, CPEDC, CPMA, pediatric solutions consultant at Vermont-based PCC.

Worldwide statistics bear this out: “1 in 4 youth globally are experiencing clinically elevated depression symptoms, while 1 in 5 youth are experiencing clinically elevated anxiety symptoms,” during the COVID-19 pandemic (Source: jamanetwork.com/journals/jamapediatrics/fullarticle/2782796),

 So now, more than ever, you need to make sure you have all the ICD-10 codes for child and adolescent mental health at your fingertips. These pointers will help.

Ask, Is it Depression, Anxiety, or Both?

The difference between the depression and anxiety codes is easy to determine. Depression diagnoses are coded either to F32.- (Depressive episode) or F33.- (Major depressive disorder, recurrent), while anxiety disorders other than phobias are grouped under the F41.- (Other anxiety disorders) group.

But one diagnosis is particularly tricky to pin down.

Depression linked with anxiety: If the pediatrician’s notes indicate a diagnosis of anxiety depression or mixed anxiety and depressive disorder, you will need to query your pediatrician to find out if they have determined a link between the two conditions for a definitive code. Per the AHA ICD-10-CM Coding Clinic you should assign F32.9 (Major depressive disorder, single episode, unspecified) and F41.9 (Anxiety disorder, unspecified) “when the documentation has not established a linkage between the depression and the anxiety.” You might also assign F41.8 (Other specified anxiety disorders), which is a code that “includes anxiety depression and mixed anxiety and depressive disorder” and identifies “a distinct clinical diagnosis” known as “mixed anxiety and depressive disorder, also known as MADD” (2021, Volume 8, Number 1).

Another code choice, F34.1 (Dysthymia), may also come into play, as one of the synonyms for this condition is “persistent anxiety depression.” Here, though, the key term is “persistent,” as the condition is not episodic, like depression, but continuously experienced for a period of at least a year in childhood or adolescence (see, for example, www.nami.org/Blogs/NAMI-Blog/January-2018/Understanding-Dysthymia).

Determine Level for Major Depression Dx

Coding depression “can be a little tricky, as the level of depression will play a role in determining the diagnosis,” says Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California. The problems begin when you glance through the tabular list and realize the F32.- and F33.- codes all feature major, but not minor, depression classifications.

Why? “Given … there is no natural discontinuity between minor depression and mild major depression in routine clinical practice,” according to the National Collaborating Centre for Mental Health (UK) (NCCMH) (Source: www.ncbi.nlm.nih.gov/books/NBK82926/), ICD-10 classifies minor depression as “major depressive disorder, mild,” then adds two further levels to major depression: moderate or severe.

Factor Duration and Course Into the Diagnosis

The length of the patient’s depressive episodes will also be reflected in the ICD-10 code choice. “Traditionally the minimum duration of persistent symptoms for major depression is 2 weeks and for chronic depression (or dysthymia) 2 years,” according to NCCMH, though your pediatrician must be the one to make the call.

Along with duration, there is the course of the depression, which is typically described as either “single episode” or “recurrent.” “Conventionally, classification has distinguished between a single episode and two or more episodes (recurrent depression),” according to NCCMH, though your pediatrician’s determination will rest on the number of episodes and their pattern (e.g., the length of time between them). As the NCCMH notes, “someone who has had two episodes separated by decades has a different clinical course from someone with three episodes in a few years.” But again, you must defer to your pediatrician’s determination here.

Putting it all Together

A 13-year-old patient comes to your practice and tells your pediatrician they have been feeling depressed for the last month. They have lost interest in their favorite pastimes, they cannot seem to concentrate, and they are having trouble sleeping. The patient does not have a history of depression.

The diagnosis: Based on these notes, your pediatrician would probably diagnose the patient with major depression (based on a depressed mood that is persistent, or longer than two weeks, and the loss of interest in pleasurable things). Without feelings of worthlessness or suicidal ideations, however, it is likely the pediatrician would only regard the depression level as moderate. And without a history of depression, the diagnosis would likely be of a single episode and not recurrent. That would lead the pediatrician to a diagnosis of F32.1 (Major depressive disorder, single episode, moderate).