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ICD-10 Guide
ICD-10 CodesF32.1

F32.1

Billable

Major depressive disorder, single episode, moderate

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 F32.1 is a billable code used to indicate a diagnosis of major depressive disorder, single episode, moderate.

Key Diagnostic Point:

Major depressive disorder (MDD) is characterized by a persistent feeling of sadness or a lack of interest in previously enjoyed activities. A single episode of moderate MDD is diagnosed when an individual experiences a range of depressive symptoms that significantly impair daily functioning but do not meet the criteria for severe depression. Symptoms may include low energy, difficulty concentrating, changes in appetite or sleep patterns, feelings of worthlessness, and recurrent thoughts of death or suicide. The diagnosis is made based on clinical assessment, including a thorough patient history and standardized screening tools. Treatment typically involves psychotherapy, pharmacotherapy with antidepressants, and lifestyle modifications. Mood stabilizers may be considered if there is a co-occurring bipolar disorder. It is crucial to assess suicide risk in patients with moderate MDD, as they may exhibit suicidal ideation or behaviors, necessitating close monitoring and intervention.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between moderate and severe depressive episodes
  • Assessing co-morbid conditions such as anxiety or bipolar disorder
  • Understanding the impact of treatment modalities on coding
  • Documenting the severity and duration of symptoms accurately

Audit Risk Factors

  • Inadequate documentation of symptom severity
  • Failure to assess and document suicide risk
  • Misclassification of episode severity
  • Lack of follow-up documentation on treatment response

Specialty Focus

Medical Specialties

Psychiatry

Documentation Requirements

Comprehensive psychiatric evaluation, including history of present illness, mental status examination, and risk assessment.

Common Clinical Scenarios

Initial evaluation of a patient presenting with depressive symptoms, follow-up visits to monitor treatment response.

Billing Considerations

Ensure thorough documentation of all symptoms and their impact on daily functioning.

Primary Care

Documentation Requirements

Routine screening for depression using validated tools, documentation of treatment plans and referrals.

Common Clinical Scenarios

Patients presenting with fatigue, sleep disturbances, or changes in appetite; follow-up on antidepressant therapy.

Billing Considerations

Documenting the patient's psychosocial context and any referrals to mental health specialists.

Coding Guidelines

Inclusion Criteria

Use F32.1 When
  • According to ICD
  • 10 guidelines, F32
  • 1 should be used when a patient meets the criteria for a single episode of moderate major depressive disorder
  • Documentation must reflect the duration and severity of symptoms, and any co
  • occurring conditions should be coded appropriately

Exclusion Criteria

Do NOT use F32.1 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

90834CPT Code

Psychotherapy, 45 minutes with patient

Clinical Scenario

Used during therapy sessions for patients diagnosed with moderate MDD.

Documentation Requirements

Document the duration of the session and the therapeutic interventions used.

Specialty Considerations

Psychiatrists may need to provide detailed notes on treatment progress.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of depressive disorders, improving the accuracy of diagnoses and treatment planning. F32.1 provides a clear distinction between severity levels, which is essential for appropriate treatment and reimbursement.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of depressive disorders, improving the accuracy of diagnoses and treatment planning. F32.1 provides a clear distinction between severity levels, which is essential for appropriate treatment and reimbursement.

Reimbursement & Billing Impact

reimbursement.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What are the key symptoms to document for F32.1?

Key symptoms include persistent low mood, loss of interest in activities, changes in appetite or sleep, fatigue, feelings of worthlessness, and suicidal thoughts. Documenting the duration and impact of these symptoms is crucial.