ICD-10 Coding for Major Depressive Disorder, Moderate(F32.1, F33.1)
Complete ICD-10-CM coding and documentation guide for Major Depressive Disorder, Moderate. 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, Moderate
F32-F33Primary Range
Depressive episodes and recurrent depressive disorder
This range includes codes for single and recurrent episodes of major depressive disorder, including moderate severity.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| F32.1 | Major depressive disorder, single episode, moderate | Use for a single episode of moderate major depressive disorder with 4-6 symptoms. |
|
| F33.1 | Major depressive disorder, recurrent, moderate | Use for recurrent episodes of moderate major depressive disorder. |
|
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 moderate major depressive disorder
Essential facts and insights about Major Depressive Disorder, Moderate
Primary ICD-10-CM Codes for major depressive disorder moderate
Decision Criteria
clinical Criteria
- Presence of moderate symptoms and functional impairment
Applicable To
- Moderate single episode of major depression
Excludes
- Recurrent depressive disorder (F33.-)
Clinical Validation Requirements
- Presence of 4-6 symptoms from DSM-5 criteria
- PHQ-9 score between 10-14
- Functional impairment in daily activities
Code-Specific Risks
- Risk of undercoding if symptoms are not fully documented
Coding Notes
- Ensure documentation specifies the episode type and severity.
F33.1 - Major depressive disorder, recurrent, moderate
Use for recurrent episodes of moderate major depressive disorder.
Applicable To
- Moderate recurrent episodes of major depression
Excludes
- Single episode depressive disorder (F32.-)
Clinical Validation Requirements
- History of previous depressive episodes
- Current episode with 4-6 symptoms
- PHQ-9 score between 10-14
Coding Notes
Document the recurrence and severity of the depressive episodes.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Disruption of family by separation or divorce
Z63.5Differential 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, Moderate to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code F32.1.
Impact
Clinical: May lead to inappropriate treatment plans., Regulatory: Increases risk of non-compliance with coding standards., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Use templates that prompt for episode type, Regular training on documentation standards
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Increases risk of audit failures., Data Quality: Reduces accuracy of health records.
Mitigation Strategy
Ensure documentation specifies the episode type and severity to use F32.1 or F33.1.
Impact
High risk of audit if unspecified codes are used when specific codes are applicable.
Mitigation Strategy
Ensure detailed documentation of symptoms and episode type.
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, Moderate, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Major Depressive Disorder, Moderate
Use these documentation templates to ensure complete and accurate documentation for Major Depressive Disorder, Moderate. These templates include all required elements for proper coding and billing.
New diagnosis of moderate MDD
Specialty: PsychiatryRequired Elements
- Patient history
- Symptom count and duration
- PHQ-9 score
- Functional impairment
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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