Pediatric Coding Alert

Question: A 13-year-old patient reported feeling depressed for the last month. They have lost interest in their favorite pastimes, cannot concentrate, and they are having trouble sleeping. The patient does not have a history of depression. The pediatrician documented “major depressive disorder (moderate).” But I’m wondering if this is a mistake because this case seems minor, not major. Which code should I use?

Illinois Subscriber

Answer: It’s never a bad idea to query the provider if you suspect an error. However, in this case, it’s probably safe to say the provider’s documentation is accurate. This would code to F32.1 (Major depressive disorder, single episode, moderate).

Here’s why: First of all, coding depression is tough because when you take a look at the tabular list, you’ll see F32.- and F33.- codes all feature major, but not minor, depression classifications. “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.

Second, the ICD-10 code choice will depend partly on the length of a patient’s depressive episodes. “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, the course of depression is something your pediatrician considers. Typically, that’s 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. Again, this is for your pediatrician to determine, which according to the notes, they have.

Your pediatrician therefore probably diagnosed 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. The level is noted as “moderate,” which is also based on clinical judgment after consulting with the patient. There is no history of depression noted, which classifies this as a single episode rather than recurrent. That would lead the pediatrician to a diagnosis of F32.1.