Updated on: March 14, 2016

Major Depression No Laughing Matter: Serious Diagnosis Requires New Documentation, Coding and Privacy Focus

By Kimberly Janet Carr, RHIT, CCS, CDIP, CCDS, AHIMA-Approved ICD-10-CM/PCS Trainer
Original story posted on: September 8, 2014

The recent death of world-renowned actor and comedian Robin Williams came as a shock to many. Like many dealing with major depression and other mental health conditions, Mr. Williams suffered in silence. His diagnosis was just another little-known fact in a very celebrated and public life.


Dr. Debra Peel, a practicing psychiatrist and founder of Patient Privacy Rights, recently stated that some “10 percent of all hospital admission patients have some type of mental illness diagnosis,” further suggesting that many more patients may be delaying or avoiding treatment for dangerous conditions such as depression because of privacy concerns.

Mental health diseases are no laughing matter. Neither is the documentation and coding of these cases in ICD-10. This article summarizes key points to remember when handling major depression and depressive disorder not-otherwise-specified (NOS) cases in three areas: documentation, coding and privacy.

Major Depression Differences to Know

In the ICD-9 coding world, code number 296.20, Major Depression, single episode, unspecified is used, with a secondary diagnosis a CC. With the conversion to ICD-10, because 296.20 is an unspecified code, it loses its value as a CC and will translate (along with ICD-9 code 311, Depressive Disorder, not otherwise specified) to ICD-10 code F32.9, Major Depressive Disorder, single episode, unspecified. This code is not a CC in the ICD-10 world. In order for 296.20 to maintain its value as a CC, the physician must document the acuity of the major depression. 

For example, the physician must document whether the depression is mild, moderate, severe, or severe with psychotic features in order to qualify for a CC; he or she cannot translate to the same code as depression NOS .

Per the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), which is published by the American Psychiatric Association, major depression is defined as having one or more major depressive episodes in a period of two weeks or more, in a case in which a person has either depressed mood, the loss of interest or pleasure in nearly all activities, and at least five or more of the following symptoms nearly every day:

  • Depressed mood, by a person's own report or as observed by others;
  • Significantly diminished interest or pleasure in all, or almost all, activities most of the day;
  • Significant change in weight not due to dieting;
  • Insomnia or hypersomnia;
  • Observable physical agitation or lethargy;
  • Fatigue or loss of energy;
  • Feelings of worthlessness or excessive or inappropriate guilt;
  • Difficulty thinking clearly or concentrating or indecisiveness; and
  • Regular thoughts of death or suicide (either unplanned, planned, or attempted).

To meet clinical standards these symptoms also must cause significant distress or impairment in social, occupational, or other important areas of functioning.

The major depression must also not be caused or explained by the following:

  • Effects of drugs or medication
  • A medical condition
  • Bereavement

Depressive Disorder NOS More General

Per the DSM-5, depressive disorder NOS is a more general category of depressive disorders that do not fit the descriptions of major depression. Examples of this diagnosis would be:

  • Having episodes of two weeks or more with the symptoms matching fewer than the five described above for major depression
  • Having episodes of two days up to two weeks bearing similarities to a major depressive episode, at least once a month for at least a year

To meet clinical standards these symptoms also must cause significant distress or impairment in social, occupational, or other important areas of functioning.

As detailed above, the DSM-5 definitions of major depression and depression NOS describe two very different types of patients.

Coding Advice

Those diagnosed with major depression should have a higher severity-of-illness score and also will be more resource-consumptive (close observation by nurses, etc.) versus those diagnosed with unspecified depression. But without the specific documentation by the physician, these two very different diagnoses will be captured with the same ICD-10 code even though patients with these conditions are different and have different symptoms.

Coders should work closely with clinical documentation specialist and physician teams to understand the differences and ensure that correct documentation is included in the chart. By working together, these three teams will help secure correct reimbursement for their organizations under ICD-10.


Check Your Payers

Furthermore, revenue cycle teams should review payor contracts to confirm coverage for inpatient reimbursement. This is especially important for hospitals with inpatient psychiatric units. While some contracts will cover mental diagnoses under inpatient status, others will not.

For example, an emergency patient admitted for seizures may be diagnosed with alcohol withdrawal. Coded correctly as alcohol withdrawal, this case would be assigned a mental health MS-DRG and considered non-reimbursable for inpatient treatment by some payers. Checking payer contracts early and often prevents surprise denials for mental health cases.

The next area of health information management (HIM) concern for patients with mental disorders is HIPAA privacy and security compliance.

Mental Health Privacy Requires Tighter Controls, Stricter Compliance

Robin Williams’s death brings to light important HIM concerns regarding privacy. Celebrities may be even more at risk for shunning treatment due to privacy concerns than the general public. In addition, most hospital staff terminations are caused by unauthorized viewing of celebrity records.

The final HIPAA omnibus rule ramped up patient privacy and security compliance for healthcare’s covered entities (CEs) and business associates (BAs). With OCR’s privacy audits underway, there are several cautionary steps organizations can take to further protect the privacy of individually identifiable protected health information (PHI) for mental health patients.

Segment – Work with your IT vendors to establish segmented areas of your electronic health record (EHR) and other systems for mental health information.

Establish – Beyond complying with routine HIPAA policies and procedures, establish specific guidelines governing the collection, management, and release of mental health records.

Educate – Incorporate targeted educational content and awareness for mental health patient information within overall HIPAA training programs. Include mention of patient concerns and the number of patients forgoing medical treatment due to privacy and security concerns.

Enforce – Conduct routine internal audits of access logs for mental health patients and consider heightened employee penalties for breach.

Use the Delay

Additional time has been granted to educate clinical documentation improvement (CDI) teams, coders, and physicians on the differences in severity of illness between major depression and depressive disorder NOS.

Use this time wisely to ensure successful documentation of these two conditions prior to the implementation of ICD-10. They are two unique diagnoses and patient groups.

Finally, work with your compliance department and IT services division to completely protect mental health patient information. Take every step necessary to ensure privacy and fully cover these patients who desperately need your care.

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.