Medical Codes to Document Depression, a Common Mental Health Condition

The American Psychiatric Association (APA) defines depression or major depressive disorder as a common and serious medical illness that negatively affects the way how one feels, thinks and acts. It is also a leading cause or risk factor for suicide. With proper diagnosis and treatment, the vast majority of people with depression can overcome it. Outsourcing medical billing for this mental health specialty helps psychiatrists focus more on patient care than on documentation tasks. According to a recent survey from the Pew Research Center, teen depression in the U.S. has increased in the past decade and most boys and girls are seeing mental health as a major problem. Different forms of depression include postpartum depression, seasonal affective disorder, persistent depressive disorder, and psychotic depression.

When documenting major depressive disorder (MDD), make sure to include three key elements such as –

• Episode – Single or Recurrent
• Severity – Mild (patient experiences at least 5 of the symptoms for a diagnosis of MDD), moderate (patient experiences at least 7 to 8 symptoms) or severe (patient experiences most or all of the symptoms)
• Clinical Status – In partial or full remission

Symptoms and Screening of Depression

Risk factors that can play a role in depression include genetics, personality and environmental factors. Symptoms for this psychiatric condition can vary from mild to severe including feeling sad, loss of interest or pleasure in activities once enjoyed, changes in appetite, disturbed sleeping or sleeping too much, loss of energy or increased fatigue, increase in purposeless physical activity, feeling worthless or guilty, difficulty thinking, concentrating or making decisions, and thoughts of death or suicide.

The correct diagnosis of major depression is especially important because medication therapies are ineffective for minor depression. Diverse tools are available to assist primary care physicians in accurate diagnosis of depression. Such tools would help in effective management of this mental health condition too. Patient Health Questionnaire (PHQ) is the most commonly used instrument for depression screening in the United States.

Depression Screening HCPCS/CPT Code

• G0444 – Annual depression screening, 15 minutes

Since April 2012, contractors are recommended to pay for annual depression screening claims only when services are provided at the following Places of Service (POS):

• 11 – Office
• 22 – Outpatient hospital
• 49 – Independent clinic
• 71 – State or local public health clinic

Most people receive treatment for depression in primary care settings. Medicaid recommends that mental health services can be delivered via inpatient hospital services, outpatient hospital services, federally qualified health center (FQHC) and rural health center (RHC) services, and physician services. At the same time, Medicare Part B covers mental health services provided by health professionals such as psychiatrist or other doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner and physician assistant.

ICD-10 Codes for Depression

F32 – Major depressive disorder, single episode

• F32.0 – Major depressive disorder, single episode, mild
• F32.1 – Major depressive disorder, single episode, moderate
• F32.2 – Major depressive disorder, single episode, severe without psychotic features
• F32.3 – Major depressive disorder, single episode, severe with psychotic features
• F32.4 – Major depressive disorder, single episode, in partial remission
• F32.5 – Major depressive disorder, single episode, in full remission
• F32.8 – Other depressive episodes
• F32.9 – Major depressive disorder, single episode, unspecified

CMS’ ICD-10-CM coding updates 2022 Changes in Chapter 5 include one new code for depression. F32.A Depression, unspecified This code comes under revised category F32 Depressive episode. The 2022 code set also adds to this chapter F78.A1 SYNGAP1-related intellectual disability and F78.A9 Other genetic related intellectual disability under new subcategory F78.A – Other genetic related intellectual disabilities.

F33 Major depressive disorder, recurrent

F33 codes refer to recurrent episodes of major depression

• F33.0 Major depressive disorder, recurrent, mild
• F33.1 Major depressive disorder, recurrent, moderate
• F33.2 Major depressive disorder, recurrent severe without psychotic features
• F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms
• F33.4 Major depressive disorder, recurrent, in remission NON-BILLABLE
• F33.8 Other recurrent depressive disorders
• F33.9 Major depressive disorder, recurrent, unspecified

Other Codes for Depression

• F03.90 Unspecified dementia without behavioral disturbance
• F34.1 Dysthymic disorder
• F43.21Adjustment disorder with depressed mood
• F06.31 – Mood disorder due to known physiological condition with depressive features
• F06.32 – Mood disorder due to known physiological condition with major depressive-like episode
• F25.1- Schizoaffective disorder, depressive type

Use E/M CPT codes 99201–99205 or 99211–99215 with a depression claim along with ICD-10-CM diagnosis codes.

Depression Treatment

Treatment options for depression include administering medications such as antidepressants or other psychotropic medications for six or more months after symptoms have improved, psychotherapy, cognitive behavioral therapy (CBT) that helps a person to recognize distorted thinking and then change behaviors and thinking, and Electroconvulsive Therapy (ECT) for patients with severe major depression or bipolar disorder who have not responded to other treatments.

Most traditional face-to-face, individual psychotherapy sessions should be billed only for 45 minutes (90834), while CPT code 90791 is used for billing an intake interview and 90847 for family therapy. Commonly used CPT codes include:

• 90791 Psychiatric/psychological diagnostic interview without medical services (intake interview)
• 90792 Psychiatric diagnostic interview (for prescribers / medical services)
• 90834 Individual psychotherapy, 45 minutes
• 90837 Individual psychotherapy, 60 minutes
• 90847 Family psychotherapy with patient present

Medical coders must make sure not to use psychiatric or psychotherapy CPT codes (90801–90899) with a depression claim for a primary care setting, as these codes tend to be reserved for psychiatric or psychological practitioners only. Psychiatry medical coding services provided by an experienced medical billing company can assist mental health specialists to submit clean claims and get proper reimbursement on time.

Disclaimer

Medical codes change periodically, based on CMS updates. The codes and other information in this blog are for informational and educational purposes only. Our content does not constitute professional advice of any kind.