Tips for Documenting Major Depressive Disorder

Published July 2024

MVP is committed to supporting Providers by offering coding tips that help create more efficiency when closing gaps in care and improving the physical and mental health of patients.

Major Depressive Disorder(MDD), also known as clinical depression, is one of the most common mental health conditions and can affect anyone. The stigma of depression causes it to be a silent illness for countless people. 

Below are some tips for identifying and documenting MDD in your patients:

• Avoid “depression, unspecified” to reflect the current health status with specificity
• “Major” can only be explicitly documented by the clinician
• Do not forget to validate the screening tool, such as DSM-5, and the result

Document the Current Episode of Care (Single or Recurrent)

Be sure to document whether the patient is having a single or recurrent episode of MDD. A patient could also be in partial or full remission. MDD is considered clinically significant, even when a patient is in remission. 

• Document symptoms or conditions reported or found during the physical exam
• An asymptomatic patient with a previous diagnosis of MDD may be in remission
• Always indicate severity; options include mild, moderate, severe with or without psychotic features, or remission status
• It is important to also document the treatment plan and patient’s current response

For further information MDD, please contact MVP’s Risk Adjustment Provider Educators:

Julie Eisen (JEisen@mvphealthcare.com) and Christine Sutherland (CSutherland@mvphealthcare.com).