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Outpatient Major Depressive Disorder (MDD) CDI Scenario – June 2021

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.

GFR (non-AA)39404352575959


  1. 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
  2. BMI 40.0 – 44.9 (Z68.41): Exercise, follow diabetic diet. Discussed how weight impacts other organs
  3. DM (E11.65): A1C 8.4, BMI 40.6, discussed diet, exercise, weight loss.  Consider insulin
  4. CKD (N18.9) due to DM2: discussed importance of managing blood sugars/blood pressure. Cr stable, GFR 39
  5. 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).323Community Enrollee – Non-dual Benefit, aged (Female, age 65-69).323
F32.9: MDD, single episode, unspecifiedNone0F320: MDD, single episode, mildHCC 59.309
Z68.41: BMI 40.0-44.9*See coding clinic below0E66.01/Z68.41: Morbid Obesity, BMI 40.0-44.9HCC 22.250
Z68.41: BMI 40.0-44.9
E11.65: DM w/hyperglycemia
HCC 18.302E11.65: DM w/hyperglycemiaHCC 18.302
N18.9: CKDNone0N18.3: CKD stage 3, E11.22:DM2 w/diabetic CKDHCC 138 *HCC 18.069 .302
I11.0: HTNNone0I12.9: Hypertensive CKD stage 1-4None0
Calculation Factor: 4 Payment HCCs.006
Total Score: .625 Total Score 1.259 *HCC 18 only counts once

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.

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


Major Depression Index (MDI) – MDCalc

Diagnostic and Statistical Manual of Mental Disorders, 5th Edition

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.