ICD-10 Coding for Major Depressive Disorder in Remission(F32.5, F33.42, F32.9)
Complete ICD-10-CM coding and documentation guide for Major Depressive Disorder 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 Depressive Disorder in Remission
F32-F33Primary Range
Depressive episodes, including major depressive disorder
This range includes codes for depressive episodes, specifying single or recurrent episodes and remission status.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| F32.5 | Major depressive disorder, single episode, in full remission | Use when the patient has experienced a single episode of major depressive disorder and is in full remission. |
|
| F33.42 | Major depressive disorder, recurrent, in full remission | Use when the patient has experienced two or more episodes of major depressive disorder and is in full remission. |
|
| F32.9 | Major depressive disorder, single episode, unspecified | Use only if documentation is insufficient to specify episode type or remission status. |
|
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 depressive disorder in remission
Essential facts and insights about Major Depressive Disorder in Remission
Primary ICD-10-CM Codes for major depressive disorder in remission
Decision Criteria
clinical Criteria
- Patient has experienced only one episode of major depressive disorder.
documentation Criteria
- Documentation includes 'single episode' and 'full remission' with PHQ-9 score.
Applicable To
- Single episode of major depressive disorder in full remission
Excludes
- Recurrent depressive disorder (F33.-)
Clinical Validation Requirements
- Documented single episode
- PHQ-9 score <5
- No symptoms for ≥2 months
Code-Specific Risks
- Using this code without confirming the single episode status
Coding Notes
- Ensure documentation specifies 'single episode' and 'full remission'.
F33.42 - Major depressive disorder, recurrent, in full remission
Use when the patient has experienced two or more episodes of major depressive disorder and is in full remission.
Applicable To
- Recurrent episodes of major depressive disorder in full remission
Excludes
- Single episode of major depressive disorder (F32.-)
Clinical Validation Requirements
- Documented recurrent episodes
- PHQ-9 score <5
- No symptoms for ≥2 months
Coding Notes
Ensure documentation specifies 'recurrent' and 'full remission'.
F32.9 - Major depressive disorder, single episode, unspecified
Use only if documentation is insufficient to specify episode type or remission status.
Applicable To
- Depression NOS
Excludes
- Recurrent depressive disorder (F33.-)
Clinical Validation Requirements
- Lack of specific documentation on episode type or remission status
Coding Notes
Avoid using unless absolutely necessary due to lack of documentation.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Major Depressive Disorder in Remission to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code F32.5.
Impact
Clinical: May lead to incorrect treatment plans., Regulatory: Increases risk of non-compliance with coding standards., Financial: Potential for denied claims due to lack of specificity.
Mitigation Strategy
Always include specific dates for remission, Ensure PHQ-9 scores are documented
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Increases risk of audits due to lack of specificity., Data Quality: Reduces accuracy of patient records.
Mitigation Strategy
Ensure documentation specifies episode type and remission status.
Impact
Lack of specificity in documenting episode type can lead to audit flags.
Mitigation Strategy
Ensure all documentation specifies whether the episode is single or recurrent.
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 Depressive Disorder in Remission, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Major Depressive Disorder in Remission
Use these documentation templates to ensure complete and accurate documentation for Major Depressive Disorder in Remission. These templates include all required elements for proper coding and billing.
Psychiatry Discharge Note
Specialty: PsychiatryRequired Elements
- Diagnosis
- Clinical Evidence
- Maintenance Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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