Find information on moderate depression diagnosis, including clinical documentation, ICD-10 codes (F32.1, F33.1), DSM-5 criteria, differential diagnosis, and treatment options. Learn about severity specifiers, symptom assessment, and best practices for healthcare professionals involved in diagnosing and managing moderate depressive disorder. This resource offers guidance on accurate medical coding and compliant clinical documentation for mental health professionals.
Also known as
Major depressive disorder, single episode
Covers moderate single episodes of major depression.
Major depressive disorder, recurrent
Includes recurrent episodes of major depression, including moderate ones.
Persistent mood affective disorder
Dysthymia, a chronic form of depression, can present with moderate symptoms.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the depression single or recurrent episode?
Single
Current severity: Moderate?
Recurrent
Current episode severity: Moderate?
When to use each related code
| Description |
|---|
| Moderate depression symptoms impacting daily life. |
| Persistent mild depression (dysthymia). |
| Adjustment disorder with depressed mood. |
Coding moderate depression without specifying severity (mild, moderate, severe) can lead to inaccurate reimbursement and data analysis.
Failing to code co-existing anxiety or other conditions with moderate depression impacts risk adjustment and quality metrics.
Insufficient clinical documentation to support the diagnosis of moderate depression can trigger denials and compliance issues.
Patient presents with moderate major depressive disorder (MDD), also known as clinical depression, meeting DSM-5 diagnostic criteria with persistent depressed mood, anhedonia, and significant impairment in functioning for the past six weeks. Symptoms include diminished interest or pleasure in most activities, significant weight loss without dieting or increased appetite with weight gain, insomnia or hypersomnia nearly every day, psychomotor agitation or retardation observed by others, 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. The patient reports difficulty concentrating at work, impacting productivity, and strained interpersonal relationships. No manic or hypomanic episodes have been reported. Symptoms are not attributable to substance use or another medical condition. Current presentation warrants diagnosis of moderate depression, ICD-10 code F32.1, and necessitates initiation of treatment. Plan includes psychotherapy, specifically cognitive behavioral therapy (CBT), and pharmacotherapy with a selective serotonin reuptake inhibitor (SSRI) to be discussed with the patient, considering potential drug interactions and side effects. Patient education on depression management, coping mechanisms, and available support resources will be provided. Follow-up appointment scheduled in two weeks to monitor treatment response and adjust plan as needed. Prognosis cautiously optimistic with appropriate treatment and adherence. Differential diagnosis considered and ruled out included adjustment disorder with depressed mood, bereavement, and other mood disorders. Medical billing codes will reflect evaluation and management (E/M) services provided, along with appropriate codes for psychotherapy and medication management. This documentation adheres to clinical documentation improvement (CDI) guidelines for accurate and comprehensive record-keeping.