ICD-10 essentials for busy physicians who would rather be doing something else -- depression and anxiety

According to published Medicare inpatient hospital data, the code for unspecified depression, 311 Depressive disorder NOS, appears on one-fifth of hospital inpatient records covered by Medicare. That fact is itself pretty depressing — but that’s a topic for another day. We are here to look at documentation and coding in ICD-10 for people who typically are on prescribed antidepressants or anti-anxiolytics for something other than a formally diagnosed thought disorder.

There are new codes in ICD-10 for describing a patient’s social and emotional situation, and we can now do a better job of characterizing patients who are on these types of medications — by any measure a significant segment of the population and an area that is a black box in the current coded data. In the case of depression, here is some motivation to change your documentation habits for ICD-10: There is no unique code for “depression” without any further detail. Unqualified use of the word depression in the medical record is classified to major depression in ICD-10.

Below is the code in the current version of ICD-10-CM, followed by the associated notes and index entries. These can be thought of as justifiable documentation — the words or phrases that would allow anyone coding the record to use the code without any further documentation.

F32.9 Major depressive disorder, single episode, unspecified

Justifiable documentation: Depression, depressive episode/state/reaction, despondency, major/reactive/psychogenic depression

Although I do not have first-hand knowledge of the decision not to include an unspecified depression code in ICD-10, I have to believe that it was intentionally done in response to comment by the specialty societies who gave input into the development of ICD-10-CM. I imagine mental health researchers could use more nuanced data for all of these people on antidepressants. But I also note that the clinical terms from the ICD-10-CM index and tabular look like a holdover from ICD-9-CM. I trust that the mental health specialty societies who monitor such things will make their recommendations to update the accepted terminology that supports a diagnosis of major depression.

The ICD-9 code for unspecified depression, 311 Depressive disorder NOS, includes the clinical terms “depressive state” and “depression.” These terms are documented pretty often for a patient who has not been formally diagnosed with major depression. However, instead of documenting “on Wellbutrin for depression,” consider these ICD-10 alternatives. They are listed in code order, along with any additional clinical terms in the index or tabular notes that would support use of the code.

F06.32 Mood disorder due to known physiological condition with major depressive-like episode

F43.21 Adjustment disorder with depressed mood

Justifiable documentation: Situational depression, grief reaction, culture shock with depressed mood

F53 Puerperal psychosis

Justifiable documentation: Postpartum/postnatal depression

O90.6 Postpartum mood disturbance

Justifiable documentation: Postpartum blues/dysphoria/sadness

Some of the conditions described above are similarly classified in ICD-9-CM, but are not often documented and coded. F53 is new, and I included it in the interest of full disclosure, but I can’t imagine the code being used until they tone down the title. Psychosis as a synonym for postpartum depression seems pretty wide of the mark.

There are also plenty of codes classified as symptoms that may do a better job of explaining a patient’s mental state and resultant use of prescribed antidepressants. Remember, the word and in a code description means and/or in the ICD classification, so any of these single-word symptoms on their own (e.g., irritability) would justify use of the code.

R45.2 Unhappiness

R45.3 Demoralization and apathy

R45.4 Irritability and anger

R45.5 Hostility

R45.6 Violent behavior

R45.7 State of emotional shock and stress, unspecified

R45.83 Excessive crying of child, adolescent or adult

R45.84 Anhedonia

R45.851 Suicidal ideations

The same deal applies with patients on medication for anxiety who have not been formally diagnosed with an anxiety disorder — while there is an unspecified anxiety code in ICD-10, but there are many new codes in places other than the mental health chapter that provide a clearer picture of the patient’s situation. They are aspects of a patient’s life that result in significant anxiety. Examples of codes are below, along with the clinical terms included in ICD-10 that would justify using that code.

Z56.1 Change of job

Justifiable documentation: Anxiety concerning change of job, problem with adjustment to change of job

Z60.0 Problems of adjustment to life-cycle transitions

Justifiable documentation: Empty nest syndrome, phase of life problem, problem with adjustment to retirement [pension]

Again, some codes classified as anxiety-related symptoms may be the most accurate explanation for a patient’s current use of prescribed anti-anxiolytics. They are listed below. Some of them may seem pretty lightweight as a diagnosis, but that is the whole point of a symptom code — the patient has not been formally diagnosed. Since mental health diagnoses can be seen as a stigma by the culture and by the patient who has been “branded” with a diagnosis, these codes may come in handy.

R45.0 Nervousness

R45.1 Restlessness and agitation

R45.82 Worries

R45.86 Emotional lability

R45.87 Impulsiveness

These code options for patients who haven’t been formally diagnosed with major depression or an anxiety disorder typically do not change reimbursement or other calculations of how ill a patient is or how difficult to treat. But they are not hard to find or code. Consider using them.

Rhonda Butler is a senior clinical research analyst with 3M Health Information Systems. She is responsible for the development and maintenance of the ICD-10 Procedure Coding System since 2003 under contract to CMS, and for the development and maintenance of the ICD-10 General Equivalence Mappings (GEMs) and Reimbursement Mappings under contract to CMS and the CDC.  She leads the 3M test project to convert the MS-DRGs to ICD-10 for CMS, and is on the team to convert 3M APR-DRGs to ICD-10. Rhonda also writes for the 3M Health Information Systems blog.


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