Major Depressive Disorder (MDD) and Medical Record Requirements

  • June 21, 2018

    An estimated 16.2 million adults in the United States had at least one major depressive episode in 2016, according to the National Institute for Mental Health.

    Documentation matters

    Your accurate clinical documentation and coding supports high-quality care for your patients experiencing major depressive disorder (MDD). When your documentation in the patient record is specific, it helps your coding team choose the most accurate ICD-10 code(s) for the claim. National and international organizations use ICD-10 data (in the aggregate) to understand the prevalence of depression and other mental health issues.

    What to document

    Be sure to include each of these three required elements when documenting MDD:

    • Episode:
      • Single or Recurrent
    • Severity:
      • Mild: The patient experiences at least 5 of the symptoms needed for a diagnosis of MDD, which also pose a mild overall functional impairment.
      • Moderate: The patient experiences at least 7 to 8 symptoms or the symptoms pose a moderate functional impairment.
      • Severe: The patient experiences most or all of the symptoms, or the symptoms experienced pose a severe functional impairment.
    • Clinical Status:
      • In partial or full remission

    What not to document

    If MDD is the confirmed diagnosis, avoid using indefinite terms, such as “suspected” or “probable.”

    If the patient doesn’t have MDD, avoid documenting “depression” and consider documenting dysthymia, unhappiness, adjustment disorders, or reaction to severe stress; this will help the coder be able to select the most accurate ICD-10 code.

    Enlist the help of PHQ-9

    Patient Health Questionnaire-9 (PHQ-9) is the primary care practitioner’s friend.

    This questionnaire is relatively simple to administer, score, and interpret and can even be delegated to clinical staff to do while a patient is waiting. PHQ-9 can also objectively determine the severity of a major depressive episode as mild, moderate, or severe, which will help you select the appropriate ICD-10 code for claim submission.

    See this resource for additional helpful tips on documentation and coding of MDD.

  •    Email this article