According to published Medicare inpatient hospital data, the code for unspecified depression, 311 Depressive disorder NOS, appears on one-fifth of hospital inpatient records covered by Medicare. That fact is itself pretty depressing — but that’s a topic for another day. We are here to look at documentation and coding in ICD-10 for people who typically are on prescribed antidepressants or anti-anxiolytics for something other than a formally diagnosed thought disorder.
There are new codes in ICD-10 for describing a patient’s social and emotional situation, and we can now do a better job of characterizing patients who are on these types of medications — by any measure a significant segment of the population and an area that is a black box in the current coded data. In the case of depression, here is some motivation to change your documentation habits for ICD-10: There is no unique code for “depression” without any further detail. Unqualified use of the word depression in the medical record is classified to major depression in ICD-10.
Rhonda Butler is a Senior Clinical Research Analyst at 3M Health Information Systems.