Major depressive disorder, single episode, unspecified
ICD-10 F32.9 is a billable code used to indicate a diagnosis of major depressive disorder, single episode, unspecified.
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 diagnosis of a single episode of MDD, unspecified, indicates that the clinician has determined the patient meets the criteria for a major depressive episode but has not specified the severity or additional features of the episode. Symptoms may include significant weight loss or gain, insomnia or hypersomnia, fatigue, feelings of worthlessness, and recurrent thoughts of death or suicide. This code is often used when the clinician has not provided sufficient detail to classify the episode further, which can complicate treatment planning and risk assessment. The unspecified nature of the code allows for flexibility in documentation but may require additional follow-up to clarify the diagnosis and treatment approach. It is crucial for healthcare providers to conduct thorough assessments, including suicide risk evaluations, as patients with MDD may exhibit increased vulnerability to self-harm.
Detailed patient history, symptom assessment, and treatment plan must be documented.
Initial evaluation of a patient presenting with depressive symptoms, follow-up visits for medication management.
Ensure thorough documentation of suicide risk assessments and any co-occurring disorders.
Comprehensive assessment of mental health status, including screening tools and follow-up notes.
Routine screening for depression during annual wellness visits, management of chronic conditions with depressive symptoms.
Collaboration with mental health specialists may be necessary for complex cases.
Used for follow-up visits for medication management in patients diagnosed with F32.9.
Document the patient's mental status, treatment response, and any changes in symptoms.
Psychiatrists may require more detailed documentation compared to primary care providers.
F32.9 is used for major depressive disorder, single episode, unspecified, while F32.0 is for a mild depressive episode. The distinction lies in the severity of symptoms and the need for more detailed documentation in F32.9.
