Psychiatry Coding & Reimbursement Alert

Question: Our clinician arrived at a diagnosis of major depressive disorder. When I looked through the ICD-10 code list, I saw many codes for this condition. How do I select the right code to report the diagnosis?

Alabama Subscriber

Answer: When reporting a diagnosis of major depressive disorder, you will need to first check through patient documentation to see whether your clinician has identified the condition as single episode or recurrent. For single episode, you report from the F32.- (Major depressive disorder, single episode) range of codes while you need to choose from F33.- (Major depressive disorder, recurrent) for recurrent episodes of major depressive disorder.

The next step to identifying the right code would be to check for the severity of the symptoms. You have different codes for mild, moderate and severe types of major depressive disorder. For instance, if the diagnosis is mild recurrent type of major depressive disorder, you report F33.0 (Major depressive disorder, recurrent, mild). If your clinician has identified the condition as severe, you will need to check if the patient is suffering from any psychotic symptoms as this will also affect your code choice. You also have specific code choices if your clinician has identified the condition to be in remission. For example, for recurrent major depressive disorder in remission, you report F33.4 (…in remission).

Finally, note that both code families include codes to designate other depressive disorders (e.g. F33.8, Other recurrent depressive disorders) and unspecified disorders (e.g. F33.9, Major depressive disorder, recurrent, unspecified), if the documentation does not allow you to choose a more specific code.