Depression is more than a behavioral health diagnosis. It can increase disease burden and complicate management of comorbid conditions. Across care settings, depression may worsen symptom burden, affect functional status, and interfere with treatment adherence and self-management. Its impact on engagement in care and overall health outcomes makes it clinically relevant for Providers across specialties.

Documentation

Precise and detailed documentation is essential for representing the patient’s status and enabling correct code selection. Please refer to the following guidelines:

• State the diagnosis clearly: document the current depressive disorder, such as adjustment disorder and/or major depressive disorder in remission.
• Include, when applicable:
• Current status, such as active, stable, improving, worsening, or controlled
• Episode type, for example single or recurrent occurrences
• Severity, categorized as mild, moderate, or severe
• Remission status, including partial or full remission
• Presence of psychotic features
• Show visit-level support: utilize TAMPER (treat, assess, monitor/medicate, plan, evaluate, refer) to convey how depression was addressed during the encounter. Include relevant symptoms and reviewed screening results.

Coding

Accurate coding requires documentation that specifies the type, severity, and current status of the depressive disorder.