When reviewing records, if we find “depression” documented three times or more in a twelve-month period, can we assign code 296.30 for major depression, recurrent episode?
A. Under the Official ICD-9 Coding Guidelines, a diagnosis can only be coded when it is explicitly spelled out in the medical record. It cannot be inferred (even when a provider does the coding) that depression documented multiple times in a record is “major recurrent depression.” Also, the Diagnostic Coding and Reporting Guidelines for Outpatient Services, pgs 88-91, explain that a diagnosis is often not established during the first visit and it may take subsequent visits to confirm that diagnosis. All diagnoses should be supported by physician documentation. The physician should clearly document the type of depression in order to assign a more specific diagnosis code such as major depressive disorder. If only depression is documented, code 311 “depression not otherwise specified.” Official ICD-9 Coding Guidelines can be downloaded at: http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide07.pdf.
