Wiki Major Depression moderate VS Moderate Depression

[Cayden3!]

The physician documents Moderate depression f32.1. As coders are we to assume Major depression moderate although the physician does not state Major? Would you code F32.9?

 

[josette76]

Hello, have you sent a query to the provider? I wouldn't assume the major part.

 

[thomas7331]

The physician documents Moderate depression f32.1. As coders are we to assume Major depression moderate although the physician does not state Major? Would you code F32.9?

There is no ICD-10 coding distinction between 'major' and 'moderate' depression and no specific code for 'moderate depression' - F32.1 and F32.9 both contain the descriptors 'major depressive disorder', and ICD-10 directs you to this category as the default code for any depression diagnosis that is not more specific, so you are not making an assumption that this is 'major depression' by using either of these codes. I personally would not query the provider for this and would go ahead and leave the F32.1 code as the provider has chosen. F32.1 carries the descriptor 'Major depressive disorder, single episode, moderate' so using this code would capture the provider's assessment that the episode under treatment is moderate in nature. Using F32.9, although the correct code for a diagnosis of 'depression' without additional detail, and perhaps technically more correct for 'moderate depression', would only make the coding less specific and is not substantially different from F32.1.

 

[terribrown]

In a direct response from Coding Clinic to this very question, this is the direction: