Coding case studies: Depression

Medical Economics Journal, Medical Economics April 2021, Volume 98, Issue 4

Getting paid requires accurate documentation and correct code selection. In our coding case studies, we explore the correct coding for a specific condition based on a hypothetical clinical scenario. This particular scenario involves a patient presenting with symptoms of depression. See if you can choose the correct codes.

Getting paid requires accurate documentation and correct code selection. In our coding case studies, we explore the correct coding for a specific condition based on a hypothetical clinical scenario. This particular scenario involves a patient presenting with symptoms of depression. See if you can choose the correct codes.

Clinical scenario

Chief complaint

follow up for depression

History

Patient, 56, presented with continued chronic fatigue and concentration issues. Reports regular physical activity, such as swimming at the YMCA up to one hour at a time, up to four times per week. Patient has had an 8-pound weight gain since last office visit. She notes daily activities such as walking in the park and going to the YMCA. She has modified diet and has consulted with nutrition services for evaluation. Reports adherence with healthy diet provided by dietetic services. Patient is in remission from colon cancer, not currently on medication administration of chemotherapy. She states that weight gain and continued fatigue may be the result of chemotherapy. Patient denies fever, chills, headaches, weakness and light-headedness.

Review of Systems

Constitutional: Negative.Negative for activity change, appetite change, and fatigue. Positive for unexpected weight change.

HENT: Negative

Eyes: Negative

Respiratory: Negative

Cardiovascular: Negative

Gastrointestinal: Negative

Endocrine: Negative

Genitourinary: Negative

Musculoskeletal: Negative

Skin: Negative

Allergic/immunologic: Negative

Neurological: Negative

Hematological: Negative

Psychiatric/behavioral: Has had decreased concentration but no dysphoric mood, self-injury, sleep disturbance or suicidal ideas.

Physical Exam

Blood pressure: 110/70

Temperature: 97.8 °F

Height: 5’ 7”

Weight: 307 pounds

Last menstrual period: 10/08/2012

BMI: 48.08 kg/m2

Constitutional: She is oriented to person, place and time. She appears well-developed and well-nourished. She is active. No distress.

HENT:

Head: Normocephalic

Right ear: Hearing, tympanic membrane, external ear and ear canal normal.

Left ear: Hearing, tympanic membrane, external ear and ear canal normal.

Mouth/throat: Uvula is midline, oropharynx is clear and moist and mucous membranes are normal.

Eyes: Conjunctivae, extraocular muscle and lids are normal. Pupils are equal, round and reactive to light.

Neck: Normal range of motion

Cardiovascular: Normal rate, regular rhythm, S1 normal, S2 normal and normal heart sounds.Exam reveals no gallop.

No murmur heard.

Pulmonary/chest: Effort normal and breath sounds normal. No respiratory distress. She has no decreased breath sounds. She has no wheezes. She has no rhonchi. She has no rales.

Abdominal: Soft. Bowel sounds are normal. She exhibits no distension. There is no hepatosplenomegaly. There is no tenderness. There is no rigidity, no rebound and no guarding.

Musculoskeletal: Normal range of motion.

Neurological: She is alert and oriented to person, place, and time.

Skin: Skin is warm and dry. She is not diaphoretic.

Psychiatric: She has a normal mood and affect. Her speech is normal and behavior is normal.

Assessment and plan

Other fatigue.

»CBC and differential TSH

Depression, unspecified
depression type.

»Refill trazodone HCL (trazodone oral)

Morbid obesity due to excess calories.

»Continue regular exercise and healthy diet

Documentation coding requirements

When documenting depression, include the following:

Major depressive disorder

Single (in partial or full remission) or recurrent episode

Mild, moderate or severe episode

With or without psychotic features

Bipolar disorder with current episode depressed (mild or moderate severity)

Mood disorder with or without major depressive-like episode

Adjustment disorder with depressed moodPostpartum depression

Code

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

F31.30
Bipolar disorder, current episode depressed, mild or moderate severity, unspecified

F31.32
Bipolar disorder, current episode depressed, moderate

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

F32.89
Other specified depressive episodes

F32.9
Major depressive disorder, single episode, unspecified

F33.0
Major depressive disorder, recurrent, mild

F33.1
Major depressive disorder, recurrent, moderate

F33.3
Major depressive disorder, recurrent, severe with psychotic symptoms

F33.8
Other recurrent depressive disorders

F33.9
Major depressive disorder, recurrent, unspecified

F43.21
Adjustment disorder with depressed mood

F53.0
Postpartum depression

Z13.31
Encounter for screening for depression

Z13.32
Encounter for screening for maternal depression

F34.1
Dysthymic disorder

Diagnosis code

R53.83

Other fatigue

F33.1

Major depressive disorder, recurrent, moderate

E66.01

Morbid (severe) obesity due to excess calories

Z68.42

Body mass index 45.0-49.9, adult