Major depressive disorder, single episode, severe without psychotic features
ICD-10 F32.2 is a billable code used to indicate a diagnosis of major depressive disorder, single episode, severe without psychotic features.
Major depressive disorder (MDD) is characterized by a persistent feeling of sadness or a lack of interest in external activities. The diagnosis of a single episode of severe MDD without psychotic features indicates that the individual is experiencing significant impairment in daily functioning, with symptoms such as profound sadness, loss of interest or pleasure in most activities, significant weight loss or gain, insomnia or hypersomnia, fatigue, feelings of worthlessness or excessive guilt, and diminished ability to think or concentrate. Importantly, this diagnosis excludes the presence of psychotic features, such as hallucinations or delusions, which would necessitate a different coding approach. The severity of the episode is determined by the number and intensity of symptoms, as well as the degree of functional impairment. This condition can lead to increased risk of suicide, necessitating thorough risk assessments and appropriate interventions. Treatment often involves a combination of psychotherapy and pharmacotherapy, including mood stabilizers and antidepressants, to alleviate symptoms and improve quality of life.
Comprehensive mental status examination, detailed symptom history, and treatment plan.
Initial evaluation of a patient presenting with severe depressive symptoms, follow-up visits to assess treatment efficacy.
Ensure that all symptoms are documented clearly, including any functional impairments and risk assessments.
Screening tools for depression, history of present illness, and any referrals made to mental health specialists.
Routine screening for depression during annual wellness visits, management of patients with known depression.
Document any referrals to mental health services and follow-up on treatment plans.
Used for therapy sessions addressing severe depressive symptoms.
Document the duration of the session, treatment goals, and patient progress.
Psychiatrists should ensure that therapy notes reflect the severity of the patient's condition.
Key symptoms include persistent sadness, loss of interest, significant weight changes, sleep disturbances, fatigue, feelings of worthlessness, and impaired concentration. Documenting the severity and impact on daily functioning is crucial.
