ICD-10 Coding for Major Depressive Disorder, Recurrent in Remission(F33.41, F33.42)
Complete ICD-10-CM coding and documentation guide for Major Depressive Disorder, Recurrent 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, Recurrent in Remission
F33.40-F33.42Primary Range
Major depressive disorder, recurrent, in remission
This range covers the coding for recurrent major depressive disorder in remission, specifying partial or full 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 |
|---|---|---|---|
| F33.41 | Major depressive disorder, recurrent, in partial remission | Use when the patient shows improvement but still has some symptoms. |
|
| F33.42 | Major depressive disorder, recurrent, in full remission | Use when the patient has no symptoms and is 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 depressive disorder recurrent in remission
Essential facts and insights about Major Depressive Disorder, Recurrent in Remission
Primary ICD-10-CM Codes for major depressive disorder recurrent in remission
Decision Criteria
clinical Criteria
- Patient exhibits partial symptom improvement with PHQ-9 score indicating mild depression.
Applicable To
- Recurrent major depressive disorder with partial remission
Excludes
- Single episode of major depressive disorder (F32.x)
Clinical Validation Requirements
- PHQ-9 score between 5 and 9
- Presence of residual symptoms like fatigue or insomnia
Code-Specific Risks
- Misclassification if remission status is not clearly documented.
Coding Notes
- Ensure documentation specifies 'partial remission' to avoid defaulting to unspecified codes.
F33.42 - Major depressive disorder, recurrent, in full remission
Use when the patient has no symptoms and is in full remission.
Applicable To
- Recurrent major depressive disorder with full remission
Excludes
- Single episode of major depressive disorder (F32.x)
Clinical Validation Requirements
- PHQ-9 score of 4 or less
- No depressive symptoms for at least two months
Coding Notes
Ensure documentation specifies 'full remission' to avoid defaulting to unspecified codes.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Long-term use of antidepressants
Z79.899Differential 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, Recurrent in Remission to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code F33.41.
Impact
Clinical: May lead to inappropriate treatment plans., Regulatory: Non-compliance with coding standards., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Use structured templates for documentation., Regular training on coding updates.
Impact
Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of health records.
Mitigation Strategy
Ensure documentation clearly states 'partial' or 'full' remission.
Impact
Inadequate documentation of remission status.
Mitigation Strategy
Implement structured documentation templates.
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, Recurrent in Remission, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Major Depressive Disorder, Recurrent in Remission
Use these documentation templates to ensure complete and accurate documentation for Major Depressive Disorder, Recurrent in Remission. These templates include all required elements for proper coding and billing.
Patient in full remission on maintenance therapy
Specialty: PsychiatryRequired Elements
- PHQ-9 score
- Duration of remission
- Medication details
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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