Major Depressive Disorder Documentation Guide
Persistent depressive mood and loss of interest affecting daily functioning.
ICD-10 Codes: F32.0, F32.1, F32.2, F33.0, F33.1, F33.2
Common Symptoms
- Depressed mood
- Anhedonia
- Sleep disturbance
- Fatigue
- Concentration difficulties
Key Documentation Elements
- Episode type (single vs recurrent)
- Severity (mild, moderate, severe)
- Suicide risk assessment
- Current medications and response
- PHQ-9 score if administered
Documentation Challenges
- Documenting severity accurately
- Recording suicide risk assessment
- Capturing treatment response
- Tracking PHQ-9 or other screening scores
Billing Considerations
- Proper severity coding
- Single episode vs recurrent distinction
- Psychotherapy documentation if applicable
Frequently Asked Questions
How do I code depression severity?
Depression severity affects coding: mild (F32.0/F33.0), moderate (F32.1/F33.1), severe (F32.2/F33.2). Scribeable determines severity from documented symptoms and PHQ-9 scores.