Depression With Anxiety and Thoughts of Suicide in ICD-10
Depression can be a big problem in not only adults but in children and adolescents as well. This coding scenario involves assigning the appropriate codes for depression with anxiety and thoughts of suicide in ICD-10.
** This article was reviewed and updated on October 15, 2023.**
Name That Code!
Question: A 16-year-old male who has been seeing his physician for anxiety and depression for the past few years, has become highly depressed and refuses to get out of bed when he is not in school. His symptoms include crying, insomnia, decreased appetite and weight loss, decreased concentration, and suicidal thoughts with a plan. The patient has been hearing voices talking to him and states it is his mom’s voice, but she is not home when this occurs. He recently made several trips to the emergency room for panic and anxiety attacks and was treated for his symptoms. The patient is diagnosed with recurrent, severe major depressive disorder with psychotic symptoms, suicidal ideations, and panic disorder. How would you code for this scenario in ICD-10-CM?
Once you have determined the correct coding for this scenario, be sure to review some essential facts about major depressive disorder, its diagnosis, and its symptoms. Then, review the steps for locating and verifying the correct codes for the three diagnoses in ICD-10-CM.
If you want to quickly verify the answer to the above coding exercise before reading further, the ICD-10-CM codes are F33.3, R45.851, and F41.0.
Major Depressive Disorder
Major depressive disorder (MDD), also called depression, is a common medical condition that affects how a person acts, feels, and thinks. Although MDD is a treatable condition, the American Psychiatric Association, states that depression causes a person to feel sad, lose interest in activities once enjoyed, and results in emotional and physical problems that decrease the ability to function.
Symptoms of Major Depressive Disorder
Symptoms of MDD can vary from mild to severe and may include:
- Feeling sad or having a depressed mood
- Loss of interest or pleasure in activities once enjoyed
- Changes in appetite — weight loss or gain unrelated to dieting
- Trouble sleeping or sleeping too much
- Loss of energy or increased fatigue
- Increase in purposeless physical activity (e.g., inability to sit still, pacing, handwringing) or slowed movements or speech (these actions must be severe enough to be observable by others)
- Feeling worthless or guilty
- Difficulty thinking, concentrating, or making decisions
- Thoughts of death or suicide
Making a Diagnosis
In most cases, a primary care physician will be the first to see a patient about psychological symptoms and will perform a screening to make an early diagnosis of MDD. Certain criteria must be met to diagnose major depressive disorder. For instance, the symptoms of MDD :
- Must occur during the same 2-week period, representing changes in functioning.
- Must include significant problems at home, school, work, or in social situations.
- Cannot be related to other medical conditions, mental disorders, or substance use.
Moreover, at least one symptom must include a depressed mood or loss of interest, and there can be no history of mania or hypomania. According to Healthline, hypomania and mania are mood disturbances that make a person abnormally energized, both physically and mentally. Hypomania is a milder form of mania. Both forms may occur in individuals who are bipolar, but they can also occur in other people.
Treatment of Depression
An interdisciplinary approach is essential for successful treatment of MDD. An integral part of these services includes primary care physicians, psychiatrists, nurses, therapists, social workers, and case managers.
Documentation
According to the documentation provided in the above coding scenario, the patient is “highly depressed,” has “suicidal thoughts with a plan,” and “panic and anxiety attacks.” The episodes are severe and recurrent rather than a single episode, and he is “hearing voices,” which is a psychotic feature.
Coding for Major Depressive Disorders in ICD-10-CM
In ICD-10-CM, major depressive disorders (MDDs) are broken down by the episode (single and recurrent).
Major depressive disorder, single episode, is further classified by severity (mild, moderate, and severe), psychotic features (without and with), and status of current episode (partial and full remission). There are also other and unspecified single-episode codes.
The individual codes for “single episode” include:
- F32.0, Major depressive disorder, single episode, mild
- F32.1, Major depressive disorder, single episode, moderate
- F32.2, Major depressive disorder, single episode, severe without psychotic features
- F32.3, Major depressive disorder, single episode, severe with psychotic features
- F32.4, Major depressive disorder, single episode, in partial remission
- F32.5, Major depressive disorder, single episode, in full remission
- F32.9, Major depressive disorder, single episode, unspecified
Major depressive disorder, recurrent, is further classified by severity (mild, moderate, and severe), psychotic features (with and without), and full, partial, and unspecified remission. There is also an unspecified recurrent code.
- F33.0, Major depressive disorder, recurrent, mild
- F33.1, Major depressive disorder, recurrent, moderate
- F33.2, Major depressive disorder, recurrent severe without psychotic features
- F33.3, Major depressive disorder, recurrent, severe with psychotic features
- F33.40, Major depressive disorder, recurrent, in remission, unspecified
- F33.41, Major depressive disorder, recurrent, in partial remission
- F33.42, Major depressive disorder, recurrent, in full remission
- F33.9, Major depressive disorder, recurrent, unspecified
Locate and Verify
To locate Major depressive disorder, recurrent, severe with psychotic symptoms, go to the ICD-10-CM coding manual Index and look up Disorder of/depressive/recurrent/current episode/severe/with psychotic symptoms F33.3. We can verify the code in the Tabular as:
F33.3, Major depressive disorder, recurrent, severe with psychotic symptoms
Synonyms listed under F33.3 include:
- Endogenous depression with psychotic symptoms
- Major depressive disorder, recurrent, with psychotic features
- Recurrent severe episodes of major depression with mood-congruent psychotic symptoms
- Recurrent severe episodes of major depression with mood-incongruent psychotic symptoms
- Recurrent severe episodes of major depression with psychotic symptoms
- Recurrent severe episodes of psychogenic depressive psychosis
- Recurrent severe episodes of psychotic depression
- Recurrent severe episodes of reactive depressive psychosis
Be sure to read the Includes, Excludes1, and Excludes2 notes at F33 for further information.
The Excludes2 note at F01-F99 states:
“Excludes2: symptoms, signs and abnormal clinical laboratory findings, not elsewhere classified (R00-R99).”
Coding for Suicidal Ideations
Thoughts of suicide are common in patients with major depressive disorder.
Locate and Verify
To locate suicidal ideation in the Index, see Ideation, suicidal R45.851. In the Tabular, we can verify the correct code as:
R45.851, Suicidal ideations
See the note at R45.851 that states, “Excludes1: suicide attempt (T14.91).” Attempted suicide does not apply here, so we can ignore this note.
There is also a note that states, “Excludes2: symptoms and signs constituting part of a pattern of mental disorder (F01-F99).” This means if both conditions exist, we should report both conditions.
Coding for Anxiety and Panic Attacks
The patient has anxiety and panic attacks. Fear and anxiety can cause panic attacks. According to Cleveland Clinic, when a person experiences a panic attack, symptoms may include fast breathing, racing heart, and sweating. People who have anxiety disorders, depression, or other mental illnesses are at increased risk for panic attacks.
Locate and Verify
To locate panic attacks in the Index, see Attack, attacks/panic F41.0. This code can also be found by looking up Anxiety, panic type F41.0.
Verified in the Tabular, the correct code is:
F41.0, Panic disorder [episodic paroxysmal anxiety]
Synonyms include: Panic attack and Panic state
So, our 3 codes for this scenario are:
- F33.3, Major depressive disorder, recurrent, severe with psychotic symptoms
- R45.851, Suicidal ideations
- F41.0, Panic disorder [episodic paroxysmal anxiety]
Final Note
When coding for major depressive disorder, it is critical to capture the episode (single or recurrent), severity (mild, moderate, severe without psychotic features or severe with psychotic features), as well as the status of the current episode (in partial or full remission). In addition, when other pertinent symptoms are documented, such as suicidal thoughts and/or anxiety, be certain to assign the codes for them as well. They are often seen in cases of major depressive disorder.
Reminder: Read all the Includes and Excludes notes before making your final code selection.
The above coding exercise is an excerpt from my article that appears at JustCoding.com under the title, “ICD-10-CM Coding For Anxiety and Depression in Children and Adolescents.” Be sure to check it out if you have a subscription.