Major Depressive Disorder (MDD) is fast becoming one of the most poorly supported conditions we find during audits, and it may stem from the fuzzily documented distinction between depression and major depression. After all, not all depression fits in the major category, and the Patient Health Questionnaire (PHQ-9), often used to document the patient’s symptoms, is not always interpreted correctly.
The PHQ-9 contains nine symptoms with various frequencies from ‘not at all’ to ‘nearly every day.’ The form itself contains a scoring mechanism that translates the total score to a category of depression (minimal, mild, moderate, moderately severe and severe). However, the criteria and their frequency don’t fully correlate to the MDD criteria promulgated by the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) of the American Psychiatric Association.
The diagnosis of MDD is for patients who suffer nearly every day from specific symptoms for at least a two-week period. These symptoms include depressed mood most of the day; markedly diminished interest or pleasure in activities most of the day; significant weight loss when not dieting, weight gain or changes in appetite; insomnia or hypersomnia; psychomotor agitation or retardation; fatigue or loss of energy; feelings of worthlessness or excessive guilt; diminished ability to think or concentrate; and/or recurrent thoughts of death or suicide ideation/attempt. Feel free to request our Bulletin on Major Depressive Disorder and also watch this short video.
The major problem in translating the PHQ-9 to an MDD diagnosis is the qualifiers from the DSM. Each criterion has additional requirements and the most significant is that five criteria must be present nearly every day.
In the last three years of audits of MDD, we have found more than 90% do not meet the criteria for the disorder. This doesn’t mean these patients are not or were not depressed; it just means the documentation did not support they were majorly depressed in accordance with the specific requirements of the disorder. The use of antidepressants is also not evidence of MDD, as patients with depression are treated with the same medications.
The final error in MDD coding and documentation is failing to apply the concept of episodes. MDD occurs in episodes (e.g., initial, recurrent), which are tied to meeting the five criteria. Once the patient’s symptoms diminish or disappear, the patient can be considered in partial or complete remission until the next episode.
This largely unsupported and erroneously coded condition is removed during an audit from patient diagnostic profiles if the evidence is not well charted. Call us for a free, no-obligation consultation to discuss MDD – or other risk adjusted conditions – in your practice.