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Improving or Maintaining Mental Health

Clinical Basis

Late-life depression is associated with increased risk of morbidity and suicide and decreased physical and cognitive functioning, as well as greater self-neglect. All of these factors are associated with increased mortality, making detection and treatment critical.1

Do not include procedure codes in the documentation. Provide a narrative instead that corresponds to the code(s) listed below.

Clinical Guidelines

  • Download and implement the evidence based practices contained in the Evidence-Based Practices Kit, Practitioners’ Guide for Working with Older Adults with Depression on the Substance Abuse and Mental Health Services Administration website at https://store.samhsa.gov/shin/content/SMA11-4631CD-DVD/SMA11-4631CD-DVD-Practioners.pdf
  • Look to the improving mood-promoting access to collaborative treatment (IMPACT) model to obtain significant improvement in the care of depression.2

Coding and Documentation Guidance

Depression and major depression are diseases that require extra time to document appropriately.

  • If patients have depression or major depressive disorders, it is imperative that physicians document the patients’ current signs, symptoms and treatment.
  • In addition, it should be noted if this is the patients’ first case of depression or if it is a subsequent/recurrent case.
  • The patients’ response (or lack thereof) to treatment must also be documented.
  • A single incidence of major depressive disorder is coded “F32.9 Major depressive disorder, single episode, unspecified.”
  • If your documentation indicates that the patients’ major depression is ongoing, coding from the “F33 Major depressive disorder, recurrent section” may be appropriate.3

HOS Tip Sheet (PDF)


1Depression in late life: review and commentary, Blazer DG J Gerontol A Biol Sci Med Sci. 2003 Mar; 58(3):249-65

2JAMA, a trial that overwhelmingly showed the effectiveness of the IMPACT collaborative care management program for late-life depres- sion in Collaborative Care Management of Late-life Depression in the Primary Care Setting: A Randomized Controlled Trial; Unutzer, et al.; Dec.  11, 2002

3See Diagnostic and Statistical Manual of Mental Disorders, DSM-5 at http://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596.

 

Associated Codes

G0444 - Annual depression screening, 15 minutes

G8431 - Screening for depression is documented as being positive and a follow-up plan is documented

G8150 - Screening for depression is documented as negative, a follow-up plan is not required

G9212 - DSM-IVTM criteria for major depressive disorder documented at the initial evaluation

G9393 - Patient with an initial PHQ-9 score greater than nine who achieves remission at 12 months as demonstrated by a 12-month (+/- 30 days) PHQ-9 score of less than five

G9395 - Patient with an initial PHQ-9 score greater than nine who did not achieve remission at 12 months as demonstrated by a 12-month (+/- 30 days) PHQ-9 score greater than or equal to five

G9396 - Patient with an initial PHQ-9 score greater than nine who was not assessed for remission at 12 months (+/- 30 days)

3351F - Negative screen for depressive symptoms as categorized by using a standardized depression screening/assessment tool (MDD)

3352F - No significant depressive symptoms as categorized by using a standardized depression assessment tool (MDD)

3353F - Mild to moderate depressive symptoms as categorized by using a standardized depression screening/ assessment tool (MDD)

3354F - Clinically significant depressive symptoms as categorized by using a standardized depression screening/assessment tool (MDD)

 

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