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ICD-10 Guide
ICD-10 CodesF33.40

F33.40

Billable

Major depressive disorder, recurrent, in remission, unspecified

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

Code Description

ICD-10 F33.40 is a billable code used to indicate a diagnosis of major depressive disorder, recurrent, in remission, unspecified.

Key Diagnostic Point:

Major depressive disorder (MDD) is a common and serious mood disorder characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in previously enjoyed activities. The recurrent form of MDD indicates that the individual has experienced multiple episodes of depression, with periods of remission in between. The term 'in remission' signifies that the individual is currently not experiencing significant depressive symptoms, although they may still be at risk for future episodes. This code is used when the specific details of the remission status are not documented, making it 'unspecified.' Clinicians often utilize mood stabilizers and antidepressants to manage symptoms, and ongoing assessment of suicide risk is crucial, particularly in patients with a history of recurrent depression. The complexity of managing MDD lies in its multifactorial nature, including biological, psychological, and social factors, which can complicate treatment and coding.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of remission status
  • Differentiation between recurrent and single episodes
  • Need for comprehensive assessment of suicide risk
  • Potential overlap with other mood disorders

Audit Risk Factors

  • Inadequate documentation of remission status
  • Failure to assess and document suicide risk
  • Misclassification of recurrent episodes
  • Lack of treatment plan documentation

Specialty Focus

Medical Specialties

Psychiatry

Documentation Requirements

Detailed patient history, treatment plans, and progress notes are essential. Documentation should include specific symptoms, duration, and any assessments related to suicide risk.

Common Clinical Scenarios

Patients presenting with recurrent depressive episodes, those in follow-up care after hospitalization, and individuals undergoing medication management.

Billing Considerations

Psychiatrists must ensure that all episodes and remission periods are clearly documented to support the use of F33.40.

Primary Care

Documentation Requirements

Documentation should include screening results, treatment plans, and follow-up notes. Regular assessments of mood and suicide risk are critical.

Common Clinical Scenarios

Patients with a history of depression presenting for routine check-ups or those experiencing new symptoms.

Billing Considerations

Primary care providers should be vigilant in documenting any changes in mood or behavior that may indicate a recurrence of depression.

Coding Guidelines

Inclusion Criteria

Use F33.40 When
  • According to ICD
  • 10 guidelines, F33
  • 40 should be used when the patient has a documented history of recurrent major depressive episodes and is currently in remission
  • It is important to ensure that the remission status is clearly indicated in the medical record

Exclusion Criteria

Do NOT use F33.40 When
  • Exclusion criteria include any current depressive episodes or other specified mood disorders

Related ICD-10 Codes

Related CPT Codes

99213CPT Code

Established patient office visit, Level 3

Clinical Scenario

Used for follow-up visits for patients in remission from recurrent depression.

Documentation Requirements

Document the patient's history, current status, and any treatment adjustments.

Specialty Considerations

Psychiatrists may require more detailed notes on symptom assessment and treatment response.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of mood disorders, including the ability to differentiate between recurrent and single episodes of depression. This specificity aids in better tracking of patient outcomes and treatment efficacy.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of mood disorders, including the ability to differentiate between recurrent and single episodes of depression. This specificity aids in better tracking of patient outcomes and treatment efficacy.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of mood disorders, including the ability to differentiate between recurrent and single episodes of depression. This specificity aids in better tracking of patient outcomes and treatment efficacy.

Resources

Clinical References

  • •
    American Psychiatric Association - Diagnostic and Statistical Manual of Mental Disorders

Coding & Billing References

  • •
    American Psychiatric Association - Diagnostic and Statistical Manual of Mental Disorders

Frequently Asked Questions

What does 'in remission' mean in the context of F33.40?

'In remission' indicates that the patient is not currently experiencing significant depressive symptoms, although they may have a history of recurrent episodes. This status is crucial for accurate coding and treatment planning.