When documenting depression, it is important to document completely and accurately in order for the most appropriate and specific code to be assigned.   The correct diagnosis and ICD-9 code may be the difference between a diagnosis that maps to an HCC and one that does not.  For example, ICD-9 code 311 (depressive disorder, NEC) does not map to an HCC, but 296.XX (major depression) maps to HCC 58. 

There are not DSM IV criteria for "depression" and "major" depression; only criteria for Major depression.   If the criteria listed in the DSM IV is met, documentation should reflect major depression.  Major depressive disorders are classified in ICD-9-CM as episodic mood disorders with category 296.  The fourth digit, 296.2x and 296.3x, is coded to define a single or recurrent episode respectively.  When applicable, designate major depression as recurrent and code 296.30, if the condition has known episodes with complete recovery between.  If a provider documents only major depression, the correct code, per ICD-9 guidelines, is 296.20.

The fifth digit is coded to define the severity of the current depressive episode:  0 - unspecified; 1 - mild; 2 - moderate; 3 - severe, without mention of psychotic behavior; 4 - severe, specified as with psychotic behavior. Continue Reading