ICD-10 Coding for Major Depression, Single Episode(F32.0, F32.1, F32.2)
Complete ICD-10-CM coding and documentation guide for Major Depression, 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 Depression, Single Episode
F32.0-F32.9Primary Range
Major depressive disorder, single episode
This range covers all severities of major depressive disorder for a single episode, from mild to severe with psychotic features.
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 exhibits mild symptoms of depression without significant functional impairment. |
|
| F32.1 | Major depressive disorder, single episode, moderate | Use when the patient exhibits moderate symptoms of depression with some functional impairment. |
|
| F32.2 | Major depressive disorder, single episode, severe without psychotic features | Use when the patient exhibits severe symptoms of depression without psychotic features. |
|
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 single episode
Essential facts and insights about Major Depression, Single Episode
Primary ICD-10-CM Codes for major depression single episode
Decision Criteria
clinical Criteria
- Patient exhibits mild depressive symptoms with minimal impact on daily functioning.
Applicable To
- Mild depressive episode
Excludes
- Recurrent depressive disorder (F33.-)
Clinical Validation Requirements
- PHQ-9 score of 5-9
- Symptoms present for at least 2 weeks
Code-Specific Risks
- Under-coding if severity increases without documentation update
Coding Notes
- Ensure documentation specifies 'single episode' and 'mild' to avoid misclassification.
F32.1 - Major depressive disorder, single episode, moderate
Use when the patient exhibits moderate symptoms of depression with some functional impairment.
Applicable To
- Moderate depressive episode
Excludes
- Recurrent depressive disorder (F33.-)
Clinical Validation Requirements
- PHQ-9 score of 10-14
- Symptoms present for at least 2 weeks
Coding Notes
Ensure documentation specifies 'single episode' and 'moderate' to avoid misclassification.
F32.2 - Major depressive disorder, single episode, severe without psychotic features
Use when the patient exhibits severe symptoms of depression without psychotic features.
Applicable To
- Severe depressive episode without psychotic symptoms
Excludes
- Recurrent depressive disorder (F33.-)
Clinical Validation Requirements
- PHQ-9 score of 15-19
- Symptoms present for at least 2 weeks
Coding Notes
Ensure documentation specifies 'single episode' and 'severe without psychotic features' to avoid misclassification.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
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 Depression, 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: May lead to inappropriate treatment plans., Regulatory: Increases risk of audit findings., Financial: Potential for incorrect billing and reimbursement.
Mitigation Strategy
Regularly review and update patient records., Ensure documentation reflects current clinical status.
Impact
Reimbursement: May result in lower reimbursement rates., Compliance: Increases risk of audit due to lack of specificity., Data Quality: Leads to inaccurate clinical data and reporting.
Mitigation Strategy
Always specify the severity of the depressive episode to use the correct code.
Impact
Inadequate documentation of severity can lead to audit issues.
Mitigation Strategy
Ensure detailed documentation of symptoms and functional impact.
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, Single Episode, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Major Depression, Single Episode
Use these documentation templates to ensure complete and accurate documentation for Major Depression, Single Episode. These templates include all required elements for proper coding and billing.
Moderate Depression Documentation
Specialty: PsychiatryRequired Elements
- Patient history
- Symptom description
- Severity assessment
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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