Tips for Coding and Documentation: Obesity and Major Depressive Disorder

Why is it important to capture the full burden of illness?

When you document all of a patient’s chronic conditions accurately at least annually and code to the highest level of specificity, you’re helping your patient get the right care at the right time. By documenting and coding all conditions, you’re ensuring that your records are complete so the patient is getting necessary care provided by your practice. Accurate diagnosis coding provides Priority Health with a snapshot of medical conditions affecting our member population and appropriately deploys case management resources.

Overweight, obesity, and morbid obesity

The relationship between BMI and mortality is well established. Help your patients understand their risks.

Provider documents diagnosis

Diagnosis of overweight, obesity, or morbid obesity can only be coded from provider documentation of the conditions.

Who can assign the BMI?

Body Mass Index (BMI) code can be assigned using non-physician clinician documentation. However, a coder is not able to calculate the BMI based on documentation.

Coding and documentation best practice

Provider documents range (Z code) for BMI, documents a weight loss plan, and also documents that the patient has “morbid obesity” if the BMI range is greater than 40, or 35 and above with a linked co-morbidity.

Information based on ICD-10-CM Guideline I.B.14 and ICD-10-CM Guideline I.C.21.c.3

From a clinical perspective, a BMI of 35+ linked to a supported co-morbidity of obesity by the clinician may be coded as morbid obesity. Co-morbidities may include but are not limited to diabetes, hypertension, sleep apnea, COPD, history of a myocardial infarction, congestive heart failure, venous stasis, atherosclerosis, osteoarthritis of weight bearing joints and cerebrovascular accident.

Information based on ICD-10-CM Guideline I.B.14 and ICD-10-CM Guideline I.C.21.c.

Major depressive disorder

Rates for routine screening for adults remain low. In 2015, only 3 percent of adults were screened. Routine screening for depression among all adults has been
recommended by the U.S. Preventive Services Task Force since 2009.

How to recognize major depressive disorder

Mood disorders that produce depression may exhibit as sadness, low self-esteem or guilt feelings. Additional manifestations may be withdrawal from friends and family, or interrupted sleep.

Coding and documentation best practice

The table is a general guide in determining how a patient’s PHQ-9 score relates to the specificity of a major depressive disorder diagnosis.


If recurrent, include if it’s mild, moderate or severe. If severe, indicate if psychosis is present. If this is a chronic reoccurrence, but symptoms appear resolved or stable, indicate the level of remission.
Be clear and concise with documentation. The patient’s score on the PHQ-9 can assist the provider in coding to the highest level of specificity.

Frequency of screening

Annual screening is encouraged; however a person with a history of mood disorders should receive more frequent outreach or screening (PHQ-2, PHQ-4 and PHQ-9).
Note: Patients shouldn’t be solely diagnosed based on their PHQ-9 score. It’s essential that the physician corroborates the PHQ-9 score with clinical determination that a significant depressive disorder is present.

Source: Priority Health

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