Major Depressive Disorder

The Diagnostic and Statistical Manual of Mental Disorders (fifth edition) defines major depression as an individual experiencing five or more symptoms during the same two-week period, with at least one of the symptoms being either depressed mood or loss of interest or pleasure. Major depression symptoms include:

  • Depressed mood most of the day, nearly every day
  • Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
  • Significant weight loss when not dieting, weight gain, or decrease or increase in appetite nearly every day
  • A slowing down of thought and a reduction of physician movement (observable by others, not merely subjective feelings of restlessness or being slowed down)
  • Fatigue or loss of energy nearly every day
  • Feelings of worthlessness or excessive or inappropriate guilt nearly every day
  • Diminished ability to think or concentrate, or indecisiveness, nearly every day
  • Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for coming suicide

Documentation and coding tips:

Documents major depressive disorder to the highest level of specificity, including recurrence, severity and current status:

  • Episode: Single episode or recurrent
  • Severity: Mild, moderate, severe, with or without psychotic symptoms
  • Status: In partial remission or in full remission

Document any underlying causes of depression, if known, such as:

  • Thyroid or adrenal gland disorders
  • Benign or malignant brain tumors
  • AIDS
  • Parkinson’s disease
  • Multiple sclerosis

Document treatment plan:

  • Psychotherapy
  • Antidepressant medications such as tricyclic antidepressants; monoamine oxidase inhibitors, or MAOIs; selective serotonin reuptake inhibitors, or SSRIs, or serotonin-norepinephrine reuptake inhibitors, or SNRIs.
  • Electroconvulsive therapy, or ECT

More information

  • A single episode of depression is commonly triggered by a life event or an underlying cause, and after a period of treatment, patients are successfully weaned off.
  • Recurrent depression is typically lifelong and, although the severity may fluctuate, patients require ongoing treatment to alleviate their depression symptoms.
  • With appropriate treatment, the patient’s depression symptoms may be controlled, in which case he or she is considered in remission. The patient still, however, carries the diagnosis of major depression.

Download Depression Guide HCC Tool

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