The Welcome Return of a Unique Code for Unspecified Depression (Depression NOS)November 11, 2021
Small modifications in the FY 2021 Index and Tabular have large implications with regard to data and comparative data collection going forward for a common diagnosis, “depression.”
Many coders who transitioned from ICD-9-CM to ICD-10-CM on October 1, 2015, quickly recognized that there was no accurate, unique code in ICD-10-CM that replaced ICD-9-CM code 311 Depression NOS.
If the provider documented “depression,” the coder was essentially forced to report the ICD-10-CM default code F32.9, Major depressive disorder, single episode, unspecified. Code F32.9 was reported regardless of whether the provider documented the terms “major” or “single episode” in the diagnostic statement.
The diagnosis “depression” may be reported as a principal diagnosis or a secondary diagnosis. In the inpatient setting, when either the ICD-9-CM code or the ICD-10-CM code was, and is, reported as a principal diagnosis the provider may be queried for more specific documentation even though both codes group to MS-DRG 430 Psychoses. When reported as a secondary diagnosis neither the ICD-9-CM code 311 nor the ICD-10-CM code F32.9 was, or is, a comorbidity or complication (CC) code, and so a query for more specific documentation would be rare.
When ICD-9-CM code 311 Depression NOS was reported during the timeframe that ICD-9-CM was in use (1979-2015), data for the diagnosis that code represents – “depression” – could be statistically analyzed and compared across the years. In simple terms, this meant that, for example, the total cases of patients with “depression” coded as 311 in ICD-9-CM, either as a principal diagnosis or as a secondary diagnosis, could be compared from year to year.
A facility could, for example, “drill down” and perhaps compare the average length of stay (ALOS) for patients with “depression” as a secondary diagnosis with patients who had the same principal diagnosis but without a secondary diagnosis of depression. The age and gender of patients with “depression” could also be compared and analyzed – were patients diagnosed at a younger or older age, was depression more prevalent in a certain gender? Was there an overall increase, decrease or fluctuations of the total number of patients with depression comparing one year to another year or years?
When referring to a diagnosis as represented by an ICD-9-CM or ICD-10-CM code, data comparability is
- The ability to allow the comparison of data across years and depends on using the same code and/or code description going from ICD-9-CM to ICD-10-CM.
- The General Equivalency Mapping (GEMS) of ICD-9-CM codes to ICD-10-CM codes was intended to facilitate data comparability, however and for whatever reason, the diagnosis “depression” (meaning “unspecified”) was mapped to “major depressive disorder, single episode, unspecified” in ICD-10-CM even in circumstances in which the provider did not specify the additional words beyond “depression” or “depressive disorder” in the diagnostic statement.
- As of October 1, 2015 all patients diagnosed with “depression” or “depressive disorder” reported as code 311 Depression NOS in ICD-9-CM were mapped to ICD-10-CM code F32.9, Major depressive disorder, single episode, unspecified.
- The comparison of data from October 1, 2015 to September 30, 2021 using ICD-10-CM code F32.9 can be performed, but the results are questionable because it is not known whether the diagnosis for these cases was “depression” or “major depressive disorder, single episode, unspecified.”
To the Rescue – The Division of Health Care Statistics (DHCS) and the ICD-10 Coordination and Maintenance (C&M) Committee
At the September 8-9, 2020 Coordination and Maintenance (C&M) Committee meeting, The Division of Health Care Statistics (DHCS) of the National Center for Health Statistics (NCHS) requested an ICD-10-CM code for “Depression NOS.” It was noted, as explained above, that ICD-9-CM had a unique code for unspecified depression (311). DHCS went on to state that “Though this is an unspecified term, it is frequently seen in medical records and needed to allow for data comparability across years.” It was also noted that “Currently in ICD-10-CM, the default for Depression NOS is code F32.9, Major depressive disorder, single episode, unspecified.”
Most importantly, the DHCS stated
- “…this [default code F32.9 for depression NOS] has been determined by subject matter experts to be clinically incorrect.
- Having an unspecified term default to major depression will prevent the true incidence of depression NOS from being captured and
- will incorrectly increase the incidence of major depression in statistical data.”
Note: The American Psychiatric Association (APA) reviewed and supported the proposal.
- The proposed modifications in the Index and Tabular were officially approved and released by the Centers for Medicare and Medicaid Services (CMS) on June 24, 2021, effective for discharges and encounters on or after October 1, 2021.
Going from “Old” to “Current”: How the Index and Tables Compare
Here we compare the old OUTDATED (FY 2021) Index to the NEW (FY 2022) Index. Note that the outdated default code for “Depression” is F32.9. Note that the new, CURRENT default code for “Depression” is F32.A.
Next, we compare the old OUTDATED (FY 2021) Tabular with the new, CURRENT (FY 2022) Tabular. Note that the old OUTDATED code for “Depression” is F32.9. Note the new, CURRENT code for “Depression” is F32.A. See also the change in the Code Category description, at the top.
“Depression NOS” vs. “Major Depressive Disorder”
Let’s circle back to one of the main reasons for this revision. Recall that the DHCS stated that the default code for depression NOS (F32.9) was “clinically incorrect,” and “having an unspecified term default to major depression will prevent the true incidence of depression NOS from being captured and will incorrectly increase the incidence of major depression in statistical data.”
Essentially, without a default code for “depression NOS,”, patients diagnosed with unspecified “depression” are included in the data with patients or clients diagnosed with “major depressive disorder.” There is no way to distinguish one from the other if both are assigned code F32.9.
The American Psychiatric Association (APA) publication “Diagnostic and Statistical Manual of Mental Disorders (DSM-5)” is the best and most comprehensive resource that explains the many diagnoses and criteria in detail. We are not permitted to reprint anything from the DSM-5 here, we can, however, provide simplified definitions of “depression, unspecified,” and “major depressive disorder” compiled from other sources. Recall that the APA reviewed and supported the code modifications.
- The abbreviation “NOS” (“Not Otherwise Specified”) is not used in DSM-5.
- In ICD-11, the abbreviation “NOS” appears as part of inclusion terms under code 6A7Z Depressive disorders, unspecified. ICD-11 code 6A7Z includes the diagnoses “depression, NOS,” “depressed, NOS,” and “depressive disorder, NOS.”
- Depression NOS or Unspecified – Patients may be diagnosed with “depression” when experiencing symptoms that cause problems in relationships or in daily activities. The symptoms may consist of feelings of sadness, tearfulness, emptiness or hopelessness and/or angry outbursts, irritability or frustration, even over small matters, and/or loss of interest or pleasure in most or all normal activities. A more definitive diagnosis may be made after further study and evaluation. For example, a patient may present in the Emergency Department with symptoms of depression, however the criteria necessary to meet a more definitive diagnosis is not apparent or able to be determined in that situation.
A treatment plan going forward may include referral to a psychiatrist or psychologist who can perform a full assessment to determine what criteria has been met to diagnose a specific type of depression and formulate a treatment plan going forward. The treatment plan may consist of counselling and/or medications as needed on an inpatient or outpatient basis. There may also be no treatment plan going forward, and the diagnosis is simply left as unspecified depression.
- Major Depressive Disorder – Patients diagnosed with “major depressive disorder” experience symptoms of depression, including those symptoms listed above plus others such as sleep disorders and/or a change in appetite. These symptoms are present for most days for at least two weeks. Major depressive disorder is also called “clinical depression.”
Once a diagnosis of clinical depression is more definitively defined, a treatment plan may consist of psychotherapy, counselling and/or psychotherapeutic medications as needed on an inpatient or outpatient basis.
Depression and the COVID-19 Pandemic
The Centers for Disease Control and Prevention (CDC) conducted a survey “Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic — United States, June 24–30, 2020” and reported that “The coronavirus disease 2019 (COVID-19) pandemic has been associated with mental health challenges related to the morbidity and mortality caused by the disease and to mitigation activities, including the impact of physical distancing and stay-at-home orders. Symptoms of anxiety disorder and depressive disorder increased considerably in the United States during April–June of 2020, compared with the same period in 2019.” The full survey and results can be found on the CDC website https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a1.htm.
A more recent article from April 6, 2021, in the AMA’s publication “Journal of the American Medical Association” CDC Study Finds Worsening Anxiety and Depression, Especially in Young Adults, During COVID-19 Pandemic” reports the findings of the online survey of 800,000 adults conducted from August 19, 2020 to February 1, 2021.
This article concludes with “Continued near real-time monitoring of mental health trends by demographic characteristics is critical during the COVID-19 pandemic,” they wrote. “These trends might be used to evaluate the impact of strategies that address mental health status and care of adults during the pandemic and to guide interventions for groups that are disproportionately affected.” https://jamanetwork.com/journals/jama-health-forum/fullarticle/2778458.
When you follow the link above, note the numerous additional articles that appear in the column to the right of the article itself.
These are just two references from reputable sources, the CDC and the AMA. We advise caution when using information from sources without first determining potential bias.
In the current environment, we are again reminded of the critically important role that the health information management professionals have in assigning and reporting accurate codes necessary for data collection and statistical analysis.
Prior to October 1, 2021, there was no accurate, unique code in ICD-10-CM that replaced ICD-9-CM code 311 Depression NOS.
Prior to October 1, 2021 the ICD-10-CM default code for “depression NOS” was F32.9 Major depressive disorder, single episode, unspecified.
Regarding data comparability and statistics, it was not possible to separate patients with “depression” from patients with “major depressive disorder, single episode, unspecified” because the same ICD-10-CM was assigned to both diagnoses.
The default code F32.9 as previously used for “depression NOS” was determined by subject matter experts to be clinically incorrect.
A new code effective October 1, 2021 for “depression NOS” or “unspecified depression” is F32.A Depression unspecified.
The new code F32.A will enable the distinction between patients diagnosed with “depression” and patients diagnosed with other, more specific types of depression.
The impact of the COVID-19 Pandemic on patients with depression is being monitored in “real time.”
The importance of accurate coding and data is critical to the potential development of strategies and interventions to address depression during the COVID-19 pandemic.