Depressive Disorder

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Did you know? Depression and Major Depression code to Depression, Unspecified.

There are three things that need to be documented to appropriately capture the severity of illness of your patients who suffer from depression:

1. Episode

  • Single
  • Recurrent

2. Activity

  • Not in remission
  • Partial remission
  • Full remission

3. If not in remission, please document the Severity

  • Mild
  • Moderate
  • Severe
    • If severe, please document any complications
      • With psychotic features
      • Without psychotic features

Good documentation examples:

  • “Major depression, recurrent, in remission”
  • “Moderate recurrent major depression”
  • “Major depression, single severe episode with psychotic features”
    *Note: Assumed not to be in remission if severity of episode graded

Download the complete tip, Depressive Disorder.