Some patients become depressed because of a physical illness. Others develop physical symptoms because they are depressed. Both types of patients generally end up in the same place: the family physician’s office. By some estimates, 5 percent to 13 percent of patients in a primary care practice have major depression.¹ Because family physicians serve as a primary source of diagnosis and treatment of depression, you need to know your options when it comes to coding for depression-related services.

Coding the diagnosis

Multiple diagnosis codes exist for coding for depression. The most general is 311, “Depressive disorder, not elsewhere classified.” Code 290.21 represents senile dementia with depressive features. Several codes can be used for reporting acute depression, including 296.2, “Major depressive disorder, single episode,” and 296.3, “Major depressive disorder, recurrent episode.” (Note that both of these codes require a fifth digit.)

Code 300.4, “Neurotic depression,” also referred to as “reactional depression,” can be used to code depression brought on by personal change or unexpected circumstances. This type of depression can become chronic, unless treated, and the affected individual is generally able to function normally. In comparison, “situational depression,” which is transient and tends to impair an individual’s ability to function more significantly than neurotic depression, may be coded as 309.0 (brief) or 309.1 (prolonged).

Lastly, maternity-related depression should be coded using 648.4. A fifth digit is required to denote the current episode of care. For example, postpartum depression would be coded as 648.44.

When a definitive diagnosis of depression is not or cannot be made, the patient’s presenting symptoms should be coded instead. For example, if a patient presents complaining of fatigue and malaise, you could code the visit using 780.79, “Other malaise and fatigue.” Unfortunately, some family physicians are tempted to code a patient’s symptoms, even in the face of a definitive diagnosis. They may do so to avoid conflict with the patient, ensure insurance coverage or to help the patient avoid the larger copays/co-insurance sometimes associated with mental health care. While such “creative coding” is well intended, it is not recommended. For one thing, it exposes physicians to potential fraud and abuse liability. It also obscures the reported incidence of depression in the primary care setting and contributes to the perception in some circles that family physicians are not capable of diagnosing and treating depression. Finally, it is contrary to correct coding principles.

Coding the services provided

Family physicians may diagnose and treat depression in the context of evaluation and management (E/M) services. Depression may be secondary to another diagnosis or it may be a primary diagnosis if the patient presents with symptoms that lead to the depression diagnosis or if depression has previously been diagnosed and is the reason for the patient’s visit.

E/M services involving the diagnosis and treatment of depression may involve a significant amount of counseling or coordination of care. When the amount of time the physician spends in counseling and coordination of care consumes more than half of the physician’s face-to-face time with the patient, it is appropriate to code the service based on time, rather than on history, exam and medical decision making. Alternatively, you may want to use prolonged services codes (99354-99355) in addition to the basic E/M service if the face-to-face time spent with the patient is at least 30 minutes or more than the typical time associated with the E/M code.

You should also familiarize yourself with the psychiatry codes (90801-90899) in the CPT manual. These are divided along diagnostic and therapeutic lines. For example, 90801 describes a “psychiatric diagnostic interview examination.” This service is generally provided during the initial phase of treatment, when the goal is to establish a diagnosis and a treatment protocol. It includes a history, mental status assessment and formulation of a treatment plan. It may also include ordering and interpreting diagnostic tests. To code a similar service typically furnished to children, use 90802, “Interactive psychiatric diagnostic interview examination using play equipment, physical devices, language interpreter, or other mechanisms of communication.”

On the therapeutic side is a series of codes (beginning with 90804) that describe individual psychotherapy. These codes are based on the setting in which the psychotherapy session occurred, the type of psychotherapy provided, the amount of face-to-face time spent with the patient and whether medical E/M services were provided on the same date as the psychotherapy service.

For example, if you provided insight-oriented psychotherapy for 20 to 30 minutes in your office without any medical evaluation and management of the patient, you would code the visit using 90804. However, if you provided medical evaluation and management in addition to insight-oriented psychotherapy you would use code 90805.

You should also be aware of CPT code 90862, “Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy.” This code should be submitted when you provide any of the following services:

• Medication management for a patient who is in psychotherapy with a nonphysician colleague (e.g. a psychologist),

• Effective treatment of a patient’s condition with psychotropic drugs alone,

• Management of a patient with an organic type of disorder (e.g., Alzheimer’s), primarily with the use of medication.

To submit 90862, the above services should involve evaluating how the medication is affecting the patient, determining the proper dosage level, prescribing medication, and noting any drug interactions or adverse drug effects. You would typically submit a mental disorders diagnosis code with this service since it is commonly used in conjunction with treatment of such disorders. However, this code may also be used in conjunction with other diagnoses, such as Alzheimer’s disease (331.0) or with an encounter for therapeutic drug monitoring (V58.83). Note that if you provide more than the minimal medical psychotherapy included in 90862, you should report a code for psychotherapy with E/M services instead, such as 90805. You should not code 90862 in addition to an E/M service, since pharmacologic management is included in the E/M service.

The codes in the psychiatry section of CPT are not designed to be limited to psychiatrists and other mental health professionals. As CPT states, “It is important to recognize that the listing of a service or procedure and its code number in a specific section of this book does not restrict its use to a specific specialty group. Any procedure or service in any section of this book may be used to designate the services rendered by any qualified physician or other qualified health care professional.” Unfortunately, some payers will still refuse to recognize family physicians as providers of primary mental health services and will not reimburse a family physician for codes in the psychiatry section of CPT.

When payers do reimburse you for psychiatric services, careful code selection can help you to maximize your revenue. For example, say you spent 20 minutes counseling an established patient with depression. If you code that visit as a 99213 (based on time), the current Medicare-allowed amount (without geographic adjustment) would be $52.65. However, if you spent that same 20-minute visit providing psychotherapy as described by 90804, the allowed amount would be $64.97. That’s a 23-percent increase in reimbursement for the same amount of physician time. (For other psychiatry and E/M services codes, see “Reimbursement rates.”)

Final thoughts

Coding for the diagnosis and treatment of depression is fraught with peril. Some patients may not like the diagnosis and some payers may not cover the service. However, if those obstacles can be overcome, diagnosis and treatment of depression can pay as well as the diagnosis and treatment of other conditions commonly seen in family medicine.