Insider's scoop | Proper coding for depression
Homecare Insider, March 28, 2016
Editor’s note: This week’s Insider’s scoop is from the March issue of Homecare DIRECTIONS’ “Coding Corner” column. Each month, ICD-10 trainer Joan L. Usher, BS, RHIA, ACE, provides expert guidance for the most vexing issues of home health coding. Click here for more information about this newsletter, or to find out more about the benefits of Beacon Institute membership.
ICD-10-CM classifies depression under Disorder, depressive, major (MDD), but more information is needed to code to the highest level of specificity. The severity of the illness (mild, moderate, or severe) and occurrence needs to be clearly documented by the provider. If the diagnosis is considered severe, the determination of whether there are psychotic features is required.
Coding for MDD must also include whether the depression is a single episode or a recurrent episode, because the corresponding category differs—it’s F32 for MDD single episode versus F33 for MDD recurrent episode.
Look in the patient’s EHR for terminology describing the occurrence. The severity of the illness will play a role in care planning, so it’s essential to query the referral source or physician for information about the severity and occurrence or recurrence. If there is no additional documentation available, the code for Depression, NOS (not otherwise specified) may be utilized—F32.9. However, the Depression, NOS code should be the exception, not the rule, to establish accurate coding.
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