Partnership Guide 2023Major Depression

For an on-demand webinar, click here or navigate to MedicareProviders.Cigna.com > Provider Education > Disease-Specific Training.Diagnostic criteriaAccording to the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5), patients must exhibit five of nine symptoms to qualify for an initial diagnosis of major depression (see below)¹A. Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition.

Depressed mood most of the day

Markedly diminished interest or pleasure in all, or almost all, activities most of the day

Significant weight loss when not dieting, or weight gain, or decrease or increase in appetite

Insomnia or hypersomnia nearly every day

Psychomotor agitation or retardation

Fatigue or loss of energy

Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional)

Diminished ability to think or concentrate, or indecisiveness

Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan or a suicide attempt or a specific plan for committing suicide

B. The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning.C. The episode is not attributable to the physiological effects of a substance or to another medical condition.

Criteria A–C represent a major depressive episode.

See the DSM-5 for complete criteria.

Remission/Severity/Recurrence²Specify remission status:

In partial remission: Symptoms of the immediate previous major depressive episode are present but full criteria are not met, or there is a period lasting less than two months without any significant symptoms of a major depressive episode following the end of such an episode.

In full remission: During the past two months, no significant signs or symptoms of the disturbance were present.

Specify current severity: Severity is based on the number of criterion symptoms, the severity of those symptoms, and the degree of functional disability.

Mild: Few, if any, symptoms in excess of those required to make the diagnosis are present, the intensity of the symptoms is distressing but manageable, and the symptoms result in minor impairment in social or occupational functioning.

Moderate: The number of symptoms, intensity of symptoms, and/or functional impairment are between those specified for “mild” and “severe.”

Severe: The number of symptoms is substantially in excess of that required to make the diagnosis, the intensity of the symptoms is seriously distressing and unmanageable, and the symptoms markedly interfere with social and occupational functioning.

Specify recurrence: For an episode to be considered recurrent, there must be an interval of at least two consecutive months between separate episodes in which criteria are not met for a major depressive episode.Diagnostic tools

The PHQ 2 and the PHQ 9 are commonly used diagnostic tools. The PHQ-9 can be accessed at: www.phqscreeners.com

The PHQ-2 is often used as a pre-screening exam if and positive followed up with a more detailed screening such as the PHQ-9.

Interpretation of test results and diagnosis of major depression is dependent on the clinician’s judgment.

Subjective documentation considerations

Elderly patients need to be screened on an annual basis for depression. The patient should be asked if, over the past two months, they have experienced:

Feeling down and out
A loss of pleasure
Fatigue or loss of energy
Weight loss or daily appetite change
Problems with concentration
Thoughts of suicide or harm

A complete review of the patient’s medications should be performed, since benzodiazepines, CNS depressants and pain medications can exacerbate depression

Careful attention to social history should be performed to review if alcohol and/or illicit drug use may be an etiological source for depression

Objective documentation considerations

Objective assessment involves a complete PMH, family and social history, and complete physical exam.

Clinicians should always assess for signs of suicide. Depressed patients should be provided the National Suicide Prevention Lifeline at 1-800-273-TALK (8255)

Documentation and coding

Document the specific type of depression.

Qualify a diagnosis of major depression through the careful considerations of:

Severity (mild/moderate/severe)
Single/recurrent episodes
Document if depressive symptoms resolution is in partial or full remission
If severe, denote if there are psychotic or anxiety symptoms present

Document a diagnostic statement that is compatible with ICD-10 nomenclature

Clinicians may document treatment plan and follow-up in the form of a medication, referral, diet, monitoring and/or ordering a diagnostic exam

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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

USPSTF. Depression in Adults: Screening. 2016. Accessed August 13, 2021. www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/depression-in-adults-screening.

Providers must confirm the accuracy of their diagnoses to ensure that diagnosis and coding practices comply with ICD-10-CM Official Guidelines for Coding and Reporting and all applicable legal requirements. Failure to address diagnosis inaccuracies can result in administrative sanctions and potential financial penalties. Accurate coding and submission activities allow us to provide the best benefits and resources possible to our customers.This guide is informational and not meant to replace the clinician’s judgment when caring for the patient.Content updated April 20232023 Medicare Advantage Partnership GuideWelcomeContentsDocumentation Best Practices2023 Medicare Advantage ICD-10-CM Quick Reference Code GuideDisease-Specific Webinar LinksConditioning Reporting GuideReporting Common ConditionsAtrial FibrillationCancerChronic Kidney Disease (CKD)Chronic Obstructive Pulmonary Disease (COPD)Congestive Heart Failure (CHF)DVT and PEDementiaDiabetes Mellitus (DM)Major DepressionObesityPeripheral Artery Disease (PAD)Substance Use/Abuse/DependenceTobacco and E-Cigarette Use/AbuseSocial Determinants of Health