Find information on Major Depressive Disorder, Single Episode, including diagnostic criteria, clinical documentation requirements, ICD-10-CM code F32, DSM-5 296.2x, differential diagnosis considerations, and treatment resources for healthcare professionals. Learn about symptom assessment, severity specifiers (mild, moderate, severe, with psychotic features, in partial remission, in full remission), and best practices for accurate medical coding and billing. Explore guidelines for mental health evaluations and effective patient care strategies related to a single episode of major depression.
Also known as
Major depressive disorder, single episode
Single episode of depressed mood, loss of interest, and other symptoms.
Mood affective disorders
Disorders characterized by disturbances in mood or affect.
Neurotic, stress-related and somatoform disorders
Mental disorders triggered by stress, often with physical symptoms.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the diagnosis Major Depressive Disorder, Single Episode?
Yes
Current episode mild, moderate, or severe?
No
Do NOT code as Major Depressive Disorder, Single Episode. Review alternate diagnoses.
Coding F32.9 lacks severity (mild, moderate, severe) impacting reimbursement and quality reporting. CDI should query for clarification.
Major Depression requires documented diagnostic criteria. Insufficient documentation leads to coding errors and audit denials.
Anxiety often accompanies depression. Overlooking comorbid anxiety diagnoses (e.g., F41.1) impacts risk adjustment and care.
Patient presents with symptoms consistent with a diagnosis of Major Depressive Disorder, Single Episode (MDD, Single Episode). The patient reports depressed mood, anhedonia, and significant weight loss over the past two months. Clinical interview reveals diminished interest or pleasure in previously enjoyed activities, insomnia, fatigue, feelings of worthlessness, and difficulty concentrating. The patient denies suicidal ideation or intent but reports significant impairment in social and occupational functioning. These symptoms meet the DSM-5 diagnostic criteria for Major Depressive Disorder, and the timeframe indicates a single episode. Differential diagnoses considered include adjustment disorder with depressed mood, bereavement, and medical conditions that can mimic depression. A complete physical examination and laboratory workup are recommended to rule out underlying medical causes. Initial treatment plan includes cognitive behavioral therapy (CBT) and pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI). Patient education regarding depression symptoms, treatment options, and prognosis was provided. Follow-up appointment scheduled in two weeks to monitor symptom improvement and medication efficacy. Medical billing codes will include ICD-10 code F32.9 for Major Depressive Disorder, Single Episode, Unspecified, and CPT codes for the evaluation and management services provided, psychotherapy, and medication management. Patient’s response to treatment and ongoing assessment of symptom severity will be documented in subsequent progress notes. Keywords: Major Depression, Single Episode, MDD, Depression Treatment, Depressed Mood, Anhedonia, DSM-5, ICD-10 F32.9, CPT Codes, Cognitive Behavioral Therapy, CBT, SSRI, Psychotherapy, Medication Management, Mental Health, Psychiatric Diagnosis, Electronic Health Record, EHR, Medical Billing, Clinical Documentation.