Help needed: recurrent depression HCC 58 is being denied by payers

Our facility is part of an ACO, so capturing all relevant HCCs is very important. We developed a CDI query for this HCC following a presentation at the Outpatient CDI Conference last year. Our CDIs query the providers if a patient has a diagnosis of depression, is on home meds for depression and we continue the medication during the hospital stay, we ask if the depression is a single episode, a recurrent brief episode or a recurrent ongoing depression. We are not a psych facility, therefore our providers are not comfortable diagnosing mild, moderate, severe or saying the depression is in remission. Thus we are left coding recurrent depression as either F 33.8 (recurrent brief depressive episodes) or F 33.9 (ongoing monopolar episodes) based on provider response. However, we are now experiencing payer denials for coding and billing F33.8 or F 33.9. The payers are pushing for coding criteria and want to know how we define these diagnoses. We have done some literature research regarding these codes and it is minimal, at best. I am reaching out to ACDIS to ask for help. Does ACDIS have some definitive criteria on when to use these codes, F 33.8 /F 33.9, and some advice on how we might defend these coding payer denials?
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  • the clinical criteria are very outlined in the DSM 5-



  • I wasn't able to access the DSM 5 book on the website Laurie provided. However, I did find definitions for persistent depressive disorder and major depressive disorder, but I am looking for specific definitions for use of F 33.8 and F 33.9 ICD-10-CM codes so we are able to defend our coding payer denials. 

    Persistent Depressive Disorder; refers to a longer lasting form of depression. While Major Depressive Disorder is diagnosed if an individual experiences symptoms for at least 2 weeks, Persistent Depressive Disorder is used when symptoms of depression are present on most days for at least two years, but do not reach the severity of a major depressive episode. (Prior to the release of the DSM-5 this was more commonly known as Dysthymia.)

     

    Major Depressive Disorder (Clinical Depression); a mental health condition characterized by an inescapable and ongoing low mood often accompanied by low self-esteem and loss of interest or pleasure in activities that a person used to find enjoyable.  To meet the criteria for Major Depressive Disorder (MDD), symptoms must be present nearly every day for at least 2 weeks. MDD is also often referred to as Major Depression.

  • mevangelder- I emailed you directly with some criteria. :) :)
  • edited August 15
    If I may also point out one additional elephant in the room which was eluded to but not explicitly stated.  The request from the payer that you "define these diagnoses" is completely inappropriate.  It is not the purview of the hospital coding department, CDI, RN, or  hospital itself and in some ways not even the purview of the physician to "define a diagnosis".  The diagnoses are defined by intensive research performed by the experts in academic settings only.  Hopefully the criteria from Laurie will be helpful in accomplishing that, however i struggled with the inappropriateness of the request in the first place when I saw your post above. 

    A few more tidbits.   The DSM won't define the definitions precisely as there are ICD 10 coding conventions at play which must also be considered.

    "Other" recurrent depressive disorders in ICD 10 would be a named recurrent depressive disorder in which there was no other ICD 10 indexed entry, although it was named by the physician.

    "Unspecified" MDD recurrent would be used when simply the physican named a a generalized recurrent MDD but did not further specify it or name it in anyway.

    In fact this is an ICD 10 convention across the board.

    "other" always means a named condition by the physician without an indexed entry in the category.  (IE..((make this up)) "star bucks MDD recurrent" is a NAMED type of MDD but you are not going to find an indexed entry in ICD 10 so it goes to other (because it WAS named).
    "unspecified" always means the general category is mentioned by the MD but the MD does not provide any further documentation for a more specific code.  He did not name it in anyway further so it is "unspecified". 

    That is "coding 101" and also some what alarming that who ever you are dealing with at the insurance seems to lack a grasp of the basic....

    One last anecdote, I always laugh when a patient has been on a medication for MDD for 5 years and it is completely unspecified and defaults to MDD single episode unspecified.   What exactly is the implication there?  That the patient had one single MDD episode which lasted five continuous years??  Really?  When I run this by doctors they sort of have to admit that it must be recurrent.

    It SHOULD be perfectly acceptable to report these codes if they are the clinical truth to the best of the treating providers knowledge.  

    Insurance companies keep a list of "non-covered" vs "covered" diagnoses and they have them listed by ICD 10 code.  I would get with your CFO and try to request that list and fight the insurance company on that front as well.  If these are considered "non-covered" by the insurance company then you have little recourse as it is contractual.  However the solution would also have to be contractual through the CFO and COO/CMO etc.  

    If they ARE covered services then you may also involve legal since the insurance company keeps requesting additional information about covered services which are appropriately documented in accordance with treatment and the clinical truth being provided.

    If you suspect that the clinical truth is not being reported to the best of the MD's ability (IE, there is evidence and information in the record which could or should yield more specific codes...THAT'S when you dig deeper into the criteria (good luck with that).

    Remember that a basic rule of coding, CMS and most insurance companies is that more expensive diagnostic testing, referrals, consultants etc. are not to be done ONLY for more specific codes if it does not change the treatment plan or patient outcomes...I would leverage this rationale with the hospitals legal team to try and force the issue that they should be accepting these codes if they are appropriate...... least everyone drives up costs just to meet some arbitrary check mark in a box some where for the insurance company that has no impact on patient care.  NO ONE wants that...not even the insurance companies.
  • thanks allen- all great points.

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