ICD-10 Coding for Major Depressive Disorder, Single Episode(F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.9)
Complete ICD-10-CM coding and documentation guide for Major Depressive Disorder, Single Episode. 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, Single Episode
F32.0-F32.9Primary Range
Major depressive disorder, single episode
This range covers all severities and features of a single episode of major depressive disorder.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| F32.0 | Major depressive disorder, single episode, mild | Use when the patient presents with mild symptoms of depression and minimal functional impairment. |
|
| F32.1 | Major depressive disorder, single episode, moderate | Use when the patient exhibits moderate symptoms with noticeable functional impairment. |
|
| F32.2 | Major depressive disorder, single episode, severe without psychotic features | Use when the patient has severe depressive symptoms without psychotic features. |
|
| F32.3 | Major depressive disorder, single episode, severe with psychotic features | Use when the patient has severe depressive symptoms with psychotic features. |
|
| F32.4 | Major depressive disorder, single episode, in partial remission | Use when the patient is in partial remission with some residual symptoms. |
|
| F32.5 | Major depressive disorder, single episode, in full remission | Use when the patient is in full remission with no significant symptoms. |
|
| F32.9 | Major depressive disorder, single episode, unspecified | Use only when severity and features are not specified despite clinical inquiry. |
|
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 single episode
Essential facts and insights about Major Depressive Disorder, Single Episode
Primary ICD-10-CM Codes for major depressive disorder single episode
Decision Criteria
clinical Criteria
- PHQ-9 score and symptom count
Applicable To
- Mild depressive episode
Excludes
- Bipolar disorder (F31.-)
Clinical Validation Requirements
- PHQ-9 score 5-9
- Presence of 2-3 symptoms
- Minimal functional impairment
Code-Specific Risks
- Under-coding if severity is underestimated
Coding Notes
- Ensure documentation specifies 'single episode' and 'mild' severity.
F32.1 - Major depressive disorder, single episode, moderate
Use when the patient exhibits moderate symptoms with noticeable functional impairment.
Applicable To
- Moderate depressive episode
Excludes
- Bipolar disorder (F31.-)
Clinical Validation Requirements
- PHQ-9 score 10-14
- Presence of 4-5 symptoms
- Moderate functional impairment
Coding Notes
Document specific symptoms and their impact on daily functioning.
F32.2 - Major depressive disorder, single episode, severe without psychotic features
Use when the patient has severe depressive symptoms without psychotic features.
Applicable To
- Severe depressive episode without psychotic symptoms
Excludes
- Bipolar disorder (F31.-)
Clinical Validation Requirements
- PHQ-9 score 15-19
- Presence of 6 or more symptoms
- Significant functional impairment
Coding Notes
Ensure documentation includes severity and absence of psychotic features.
F32.3 - Major depressive disorder, single episode, severe with psychotic features
Use when the patient has severe depressive symptoms with psychotic features.
Applicable To
- Severe depressive episode with psychotic symptoms
Excludes
- Bipolar disorder (F31.-)
Clinical Validation Requirements
- PHQ-9 score 20-27
- Presence of hallucinations or delusions
- Severe functional impairment
Coding Notes
Document the presence of psychotic features explicitly.
F32.4 - Major depressive disorder, single episode, in partial remission
Use when the patient is in partial remission with some residual symptoms.
Applicable To
- Partial remission of depressive episode
Excludes
- Bipolar disorder (F31.-)
Clinical Validation Requirements
- PHQ-9 score <10
- Residual symptoms present
- Improvement from previous episode
Coding Notes
Ensure documentation reflects the remission status and residual symptoms.
F32.5 - Major depressive disorder, single episode, in full remission
Use when the patient is in full remission with no significant symptoms.
Applicable To
- Full remission of depressive episode
Excludes
- Bipolar disorder (F31.-)
Clinical Validation Requirements
- PHQ-9 score <5
- No significant symptoms
- Sustained improvement
Coding Notes
Document the full remission status clearly.
F32.9 - Major depressive disorder, single episode, unspecified
Use only when severity and features are not specified despite clinical inquiry.
Applicable To
- Unspecified depressive episode
Excludes
- Bipolar disorder (F31.-)
Clinical Validation Requirements
- Lack of specific severity or features documentation
Coding Notes
Avoid using unless absolutely necessary due to unspecified details.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Suicidal ideation
R45.851Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Dysthymia
F34.1Other specified anxiety disorders
F41.8Major depressive disorder, single episode, severe with psychotic features
F32.3Major depressive disorder, single episode, severe without psychotic features
F32.2Major depressive disorder, single episode, in full remission
F32.5Major depressive disorder, single episode, in partial remission
F32.4Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Major Depressive Disorder, Single Episode to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code F32.0.
Impact
Clinical: Inaccurate treatment planning., Regulatory: Non-compliance with documentation standards., Financial: Reduced reimbursement potential.
Mitigation Strategy
Use standardized scales like PHQ-9, Document specific symptoms and duration
Impact
Reimbursement: Potential loss of reimbursement due to unspecified coding., Compliance: Non-compliance with coding guidelines., Data Quality: Decreased data quality and specificity.
Mitigation Strategy
Ensure documentation specifies severity and features to use the correct code.
Impact
Inadequate documentation of severity can lead to audit issues.
Mitigation Strategy
Use standardized assessment tools and document findings clearly.
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, Single Episode, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Major Depressive Disorder, Single Episode
Use these documentation templates to ensure complete and accurate documentation for Major Depressive Disorder, Single Episode. These templates include all required elements for proper coding and billing.
Moderate MDD with functional impairment
Specialty: PsychiatryRequired Elements
- PHQ-9 score
- Symptom list
- Functional impact
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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