ICD-10 Coding for Major Depression in Remission(F32.4, F32.5, F33.41, F33.42)
Complete ICD-10-CM coding and documentation guide for Major Depression in Remission. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Major Depression in Remission
F32-F33Primary Range
Depressive episodes, including major depressive disorder
This range includes codes for major depressive disorder, both single and recurrent episodes, with remission statuses.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| F32.4 | Major depressive disorder, single episode, in partial remission | Use when a single episode of major depression is in partial remission. |
|
| F32.5 | Major depressive disorder, single episode, in full remission | Use when a single episode of major depression is in full remission. |
|
| F33.41 | Major depressive disorder, recurrent, in partial remission | Use for recurrent episodes in partial remission. |
|
| F33.42 | Major depressive disorder, recurrent, in full remission | Use for recurrent episodes in full remission. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for major depression in remission
Essential facts and insights about Major Depression in Remission
Primary ICD-10-CM Codes for major depression in remission
Decision Criteria
clinical Criteria
- PHQ-9 score between 5 and 9 with partial symptom improvement
Applicable To
- Single episode of major depression in partial remission
Excludes
- Recurrent major depressive disorder (F33.-)
Clinical Validation Requirements
- PHQ-9 score between 5 and 9
- Symptoms improved but still present for at least 2 weeks
Code-Specific Risks
- Misclassification if remission status is not clearly documented
Coding Notes
- Ensure documentation specifies 'single episode' and 'partial remission'.
F32.5 - Major depressive disorder, single episode, in full remission
Use when a single episode of major depression is in full remission.
Applicable To
- Single episode of major depression in full remission
Excludes
- Recurrent major depressive disorder (F33.-)
Clinical Validation Requirements
- PHQ-9 score less than 5
- No depressive symptoms for at least 12 months
Coding Notes
Ensure documentation specifies 'single episode' and 'full remission'.
F33.41 - Major depressive disorder, recurrent, in partial remission
Use for recurrent episodes in partial remission.
Applicable To
- Recurrent episodes of major depression in partial remission
Excludes
- Single episode of major depression (F32.-)
Clinical Validation Requirements
- PHQ-9 score between 5 and 14
- Prior episodes with current symptoms reduced but not resolved
Coding Notes
Ensure documentation specifies 'recurrent' and 'partial remission'.
F33.42 - Major depressive disorder, recurrent, in full remission
Use for recurrent episodes in full remission.
Applicable To
- Recurrent episodes of major depression in full remission
Excludes
- Single episode of major depression (F32.-)
Clinical Validation Requirements
- PHQ-9 score less than 5
- No symptoms for at least 12 months
Coding Notes
Ensure documentation specifies 'recurrent' and 'full remission'.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Major depressive disorder, recurrent, in partial remission
F33.41Major depressive disorder, recurrent, in full remission
F33.42Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Major Depression in Remission to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code F32.4.
Impact
Clinical: May lead to inappropriate treatment plans., Regulatory: Non-compliance with coding standards., Financial: Potential for incorrect billing and reimbursement.
Mitigation Strategy
Regularly review patient symptoms and update codes accordingly, Train staff on the importance of accurate coding
Impact
Reimbursement: May affect reimbursement rates due to lack of specificity., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases the accuracy of health data.
Mitigation Strategy
Use specific codes like F32.4, F32.5, F33.41, or F33.42 based on remission status.
Impact
Inadequate documentation of remission status can lead to audit issues.
Mitigation Strategy
Ensure all remission statuses are clearly documented with supporting PHQ-9 scores.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Major Depression in Remission, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Major Depression in Remission
Use these documentation templates to ensure complete and accurate documentation for Major Depression in Remission. These templates include all required elements for proper coding and billing.
Documenting major depression in full remission
Specialty: PsychiatryRequired Elements
- Diagnosis
- PHQ-9 score
- Duration of remission
- Current treatment
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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