Find information on Major Depressive Episode diagnosis, including clinical documentation requirements, ICD-10-CM code F32.9 (or F32 other specified codes), DSM-5 criteria, differential diagnosis, and treatment considerations. This resource helps healthcare professionals accurately document and code Major Depressive Episode for optimal patient care and reimbursement. Learn about symptom assessment, severity specifiers, and best practices for mental health coding and documentation.
Also known as
Depressive Episodes
Covers various types of depressive episodes, including major depressive disorder.
Mood Affective Disorders
Encompasses a wider range of mood disorders, including depression and bipolar.
Neurotic Stress-Related Disorders
Includes conditions like anxiety and adjustment disorders that can co-occur with depression.
Follow this step-by-step guide to choose the correct ICD-10 code.
Meets criteria for Major Depressive Episode?
No
Do not code as Major Depressive Episode. Consider other diagnoses.
Yes
Single or Recurrent Episode?
Coding MDE without specifying severity (mild, moderate, severe) leads to inaccurate risk adjustment and reimbursement.
Insufficient clinical documentation of required depressive symptoms can cause coding errors and denials. CDI review essential.
Incorrect coding of co-existing anxiety or substance use disorders with MDE impacts quality reporting and payment.
Patient presents with symptoms consistent with a Major Depressive Episode (MDE), fulfilling DSM-5 diagnostic criteria. The patient reports depressed mood, anhedonia characterized by markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day for the past two weeks. Additional symptoms include significant weight loss without dieting or weight gain, insomnia or hypersomnia, psychomotor agitation or retardation nearly every day, fatigue or loss of energy, feelings of worthlessness or excessive or inappropriate guilt, diminished ability to think or concentrate, or indecisiveness, and recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Symptoms are not attributable to the physiological effects of a substance or another medical condition. There is no history of a manic or hypomanic episode. Differential diagnosis includes bereavement, adjustment disorder with depressed mood, and medical conditions that can mimic depressive symptoms. Assessment includes a thorough review of medical history, including family history of mood disorders, substance use history, and current medications. The patient's current presentation suggests moderate severity. Treatment plan includes initiation of psychotherapy, specifically Cognitive Behavioral Therapy (CBT), and consideration of pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI). Patient education regarding the nature of depression, treatment options, and potential side effects of medication was provided. Follow-up appointment scheduled in two weeks to assess treatment response and adjust plan as needed. Medical billing codes will reflect the diagnosis of Major Depressive Episode, single or recurrent episode, and the specific therapeutic interventions provided. Keywords: major depressive disorder, depression symptoms, mental health, clinical diagnosis, DSM-5 criteria, MDE, CBT, SSRI, antidepressant medication, psychotherapy, mental health treatment, medical coding, ICD-10, electronic health records, EHR documentation, medical billing, healthcare, patient care, diagnostic criteria, treatment plan.