Topic: Outpatient Major Depressive Disorder (MDD)
Office visit 6/1/21: 65 y/o Caucasian, female seen in office for severe malaise and fatigue for last 6 months.
PMH: Chronic Kidney Disease, Hypertension, Diabetes Mellitus type 2
Home Medications: Metoprolol 50mg QD, Glucophage 500mg QD, ASA 81mg QD, Multivitamin, Calcium
Vitals: T: 97.5, HR:78, RR:20, BP: 130/78. HT:5’3”, WT 229lbs
PE: Patient has steadily been gaining weight since lost her job a year ago. BMI now 40.6. Has been eating fast food and junk food, not watching her diet. Sleeping a lot but still tired, no energy to exercise. No interest in usual activities. Denies ever being depressed before, although reports sister doing well on Duloxetine. PHQ-9 score of 8.
| Labs: | 5/29/21 | 2/15/21 | 11/11/20 | 7/6/20 | 4/6/20 | 1/7/20 | 9/18/19 |
| A1C | 8.4 | 8.1 | 7.2 | 6.8 | 5.7 | 5.5 | 5.4 |
| GFR (non-AA) | 39 | 40 | 43 | 52 | 57 | 59 | 59 |
| TSH | 1.6mU/L | 1.5mU/L | |||||
| BMI | 40.6 | 39.7 | 37.5 |
Assessment/Plan:
- Major Depressive Disorder, unspecified (F32.9): PHQ-9 Score: 8. Reports no depression, mania, or treatment in the past. Begin Duloxetine 20mg BID. Referred for psychotherapy
- BMI 40.0 – 44.9 (Z68.41): Exercise, follow diabetic diet. Discussed how weight impacts other organs
- DM (E11.65): A1C 8.4, BMI 40.6, discussed diet, exercise, weight loss. Consider insulin
- CKD (N18.9) due to DM2: discussed importance of managing blood sugars/blood pressure. Cr stable, GFR 39
- HTN (I10): BP stable on Metoprolol, continue current treatment
Question: Are there query opportunities based on the scenario stated above?
Discussion: Due to patient’s symptoms of Depression, she has not been active and has been gaining weight due to poor food choices. The result is a higher A1C which can also impact GFR. For compliant coding, a correlating diagnosis must accompany the code for BMI.
UASI Recommends:
- Query for specificity of Major Depressive Disorder
- For compliance, recommend query for clinical condition correlating with BMI
- Query for CKD stage
Documentation Comparison:
Documentation without Clarification: Documentation with Clarification:
| Community Enrollee – Non-dual Benefit, aged (Female, age 65-69) | .323 | Community Enrollee – Non-dual Benefit, aged (Female, age 65-69) | .323 | ||
| F32.9: MDD, single episode, unspecified | None | 0 | F320: MDD, single episode, mild | HCC 59 | .309 |
| Z68.41: BMI 40.0-44.9 | *See coding clinic below | 0 | E66.01/Z68.41: Morbid Obesity, BMI 40.0-44.9 | HCC 22 | .250 |
| Z68.41: BMI 40.0-44.9 E11.65: DM w/hyperglycemia | HCC 18 | .302 | E11.65: DM w/hyperglycemia | HCC 18 | .302 |
| N18.9: CKD | None | 0 | N18.3: CKD stage 3, E11.22:DM2 w/diabetic CKD | HCC 138 *HCC 18 | .069 .302 |
| I11.0: HTN | None | 0 | I12.9: Hypertensive CKD stage 1-4 | None | 0 |
| Calculation Factor: 4 Payment HCCs | .006 |
CDI Educational Tips:
MDD: Diagnosing Depression may seem daunting, especially if providers don’t have a copy of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM5). See below link for some pages regarding MDD. https://medicaidmentalhealth.fmhi.usf.edu/_assets/file/Guidelines/2017-2018%20Treatment%20of%20Adult%20Major%20Depressive%20Disorder.pdf
Providers may also be unsure how to determine all components required for completely and accurately coding a major depressive disorder.
- Single vs recurrent episode: Single merely means the first occurrence of an MDD episode. Once remission is achieved, any subsequent episodes are ‘recurrent’
- Mild/moderate/severe/with or without psychotic features: The Patient Health Questionnaire-9 (PHQ-9) is a screening tool used by y organizations to assist providers in determining severity of depression. Total score: 0-4 may not require treatment, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe.
- Partial remission: Full criteria of MDD are no longer met, but persistent symptoms remain, or there are no significant symptoms in a two-month time period. PHQ-9score of 5-10
- Full remission: No significant symptoms for > 2 months. PHQ-9 score <5
Morbid Obesity and BMI: In the table above, you will note that Z68.41, when entered into an HCC Risk Calculator does show a risk factor score. However, AHA Coding Clinic, Fourth Quarter 2018, p 77: BMI codes can only be assigned when a corresponding clinical condition is documented. If there is no clinical condition documented, such as overweight, obesity, or morbid obesity, query the provider for clarification. Furthermore, the provider should also document any relationship between weight and other comorbid conditions (DM, HTN, arthritis, stroke, heart disease, etc) as this demonstrates how weight impacts the management of these conditions.
CKD: Classified into one of five stages. Code any associated hypertensive or diabetic CKD per the Official Guidelines for Coding and Reporting
References:
Major Depression Index (MDI) – MDCalc
https://acphospitalist.org/archives/2019/12/coding-corner-depression
www.psychiatry.org/patients-families/depression/what-is-depression
Diagnostic and Statistical Manual of Mental Disorders, 5th Edition
KDIGO.org
CMS.gov
This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.