Wiki Depression symptoms

[mcdream]

Hi all!
How would you code:
Depression symptoms- symptoms likely related to depression.
I don't believe F32.9 is correct since not a definitive dx- "likely".
Thanks!

 

[ChattRiskCoder]

You are correct. I would not code this as definitive due to "likely".

Lots of people have symptoms of depression without a true diagnosis of depression.

 

[mcdream]

You are correct. I would not code this as definitive due to "likely".

Lots of people have symptoms of depression without a true diagnosis of depression.

Thank you chattriskcoder- is there a code to capture "depression symptoms"? (Documentation does not specify what symptoms).

 

[thomas7331]

Depression symptoms are likely to fall under category R45 - 'symptoms and signs involving emotional state'. But you have to have something documented by the provider to support a code.

 

[mcdream]

Depression symptoms are likely to fall under category R45 - 'symptoms and signs involving emotional state'. But you have to have something documented by the provider to support a code.

Without "something" documented would it be appropriate to use R45.89 or don't code at all? I appreciate your help!

 

[thomas7331]

Without "something" documented would it be appropriate to use R45.89 or don't code at all? I appreciate your help!

It's hard to speculate without looking at an actual record. But a code has to represent some piece of information in the documentation. If the provider is not giving a diagnosis, then you have to have signs or symptoms, and if the provider only documenting that the patient has symptoms but not saying what those symptoms are, then I don't know what you can code. For example, if the provider had only said the patient presented with 'symptoms of a heart attack', you would not be able to code chest pain.