Coding Tip: Major Depression

‍OHN is dedicated to providing the knowledge, resources, processes and technology you need for success in value-based care so you can do more of what you love – taking care of patients. In the months to come, we’ll share one coding tip and highlight one best practice advisory (BPA) each month to help to support your clinical documentation efforts.

Additionally, the clinical documentation excellence (CDE) team is here to support you – email riskadjustment@ochsner.org with any questions.

Capturing and Coding Major Depression

Rationale

• The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) of the American Psychiatric Association (APA) advises that major depression is a mental disorder, marked by a depressed mood and loss of interest or pleasure in all activities, that lasts for at least two weeks and represents a change from previous functioning.
• Prevalence of Major Depression increased 27.6% due to the COVID-19 pandemic (NIH, 2021)
• Symptoms are experienced by 18.4% of 65 and older population (CDC, 2019)
• Roughly two-thirds of all cases of Major Depression in the US are undiagnosed or unspecified (NIH, 2017)

The DSM-5 provides detailed and specific criteria that must be met to diagnose major depression or major depressive disorder. For example, these specific criteria include the following excerpt:

A.   Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.

1. Depressed mood most of the day
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day
3. Significant weight loss when not dieting, or weight gain, or decrease or increase in appetite
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)
8. Diminished ability to think or concentrate, or indecisiveness
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan or a suicide attempt or a specific plan for committing suicide

B.     The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

C.     The episode is not attributable to the physiological effects of a substance or to another medical condition.

How to Code & Document

Subjective

• In the subjective section of the office note, document the presence or absence of any current symptoms related to major depressive disorder.

Objective

• The objective section should include any current associated physical exam findings (such as “flat affect,” weight loss or gain, etc.).
• Include results of related diagnostic testing.

Assessment

• Specificity: Describe each final diagnosis clearly, concisely and to the highest level of specificity. Use all applicable descriptors, including the following:
• Episode – single or recurrent
• Severity – mild, moderate, severe
• Presence or absence of psychosis/psychotic features
• Remission status – partial or full

Current vs Historical

• Do not use the descriptor “history of” to describe current major depression that is still present, active and ongoing. In diagnosis coding, the phrase “history of” means the condition is historical and no longer exists as a current problem.
• Major depression that isin remission but still has impact on patient care, treatment and managementshould be included in the final assessment or impression with the currentstatus noted as “in remission.” Specify whether remission is partial or full.

Plan

• Document a specific and concise treatment plan for major depression, including date of next appointment.
• Clearly link the depression diagnosis to any medications that are being used to treat it.
• Document to whom or where referrals are made or from whom consultation advice is requested.

Coding Major Depression

Major depressive disorders are coded from categories F32 and F33. Fourth and fifth characters provide further specificity (see below). Codes in these two categories that represent major depressive disorder are as follows:

F32 Major depressive disorder, single episode

• F32.Ø - Major depressive disorder, single episode, mild
• F32.1 - Major depressive disorder, single episode, moderate
• F32.2 - Major depressive disorder, single episode, severe withoutpsychotic features
• F32.3 - Major depressive disorder, single episode, severe withpsychotic features
• F32.4 - Major depressive disorder, single episode, in partialremission
• F32.5 - Major depressive disorder, single episode, in fullremission
• F32.9- Major depressive disorder, single episode, unspecified. Includes: Depressionnot otherwise specified (NOS), Depressive disorder NOS, Major depression NOS

F33 Major depressive disorder, recurrent

• F33.Ø - Major depressive disorder, recurrent, mild
• F33.1 - Major depressive disorder, recurrent, moderate
• F33.2 - Major depressive disorder, recurrent, severe withoutpsychotic features
• F33.3 - Major depressive disorder, recurrent, severe withpsychotic symptoms
• F33.4 - Major depressive disorder, recurrent, in remission
• F33.4Ø - Major depressive disorder, recurrent, in remission,unspecified
• F33.41 - Major depressive disorder, recurrent, in partialremission
• F33.42 - Major depressive disorder, recurrent, in full remission
• F33.9 Major depressive

BPA Spotlight - Major Depression Suspect BPA

To help providers identify patients with a potential Major Depressive, Bipolar or Paranoid Disorder (HCC 59) diagnosis, the clinical documentation excellence (CDE) team in collaboration with clinical leaders have created logic within the HCC Best Practice Advisory (BPA) based on the following criteria:

HCC 59 – Major Depressive, Bipolar and Paranoid Disorders

(1 and 2) or (3 and 4)

1. Patient age is greater than or equal to 18
2. PHQ-9 score of 5 or greater in last 1 year
3. Patient age is 12-17
4. PHQ-9 score of greater than 9 in last 1 year

Identifying the Suspect BPA

• Morbid Obesity Suspected BPAs will always have a header above the condition with the language “Probable Condition Based on Epic Documentation – Major Depression” in a Grey Bar.
• Any Suspected Conditions will populate towards the top portion of the BPA tool.
• Similar to the standard Recapture Chronic Conditions in the BPA, the provider will always have the button selections of “Add Visit Diagnosis” to add the condition; “Do Not Add” to suppress the alert to the next appointment; or “N/A to Patient” to disagree and remove the condition from the tool.
• To refer to the logic outlined above, the provider can select the “link” hyperlink from the “For more information on Ochsner / Epic Probable Condition Logic click this link.”