Documentation for psychiatric disorders

Documenting psychiatric conditions to ensure correct coding can be challenging. The 3 most pertinent conditions encountered in the hospital are depression, bipolar disorder and schizophrenia. Anxiety disorders, neuroses, and personality disorders have little or no impact on the severity of illness classification of an admission.


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The term “depression” may be used non-specifically to encompass a range of mood disorders. Major depression or major depressive disorder (MDD) is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), as a depressed mood or a loss of interest or pleasure in daily activities, including numerous characteristic symptoms, nearly every day for more than 2 weeks, with impaired daily function. Several rating scales, such as the Beck Depression Inventory and Hamilton Rating Scale for Depression, classify major depression as mild, moderate, or severe (which includes psychotic features or suicidal thought).

Persistent depressive disorder (dysthymia) is a depressed mood with less severe symptoms lasting at least 2 years, which may or may not be associated with episodes of MDD. Seasonal affective disorder (SAD) is characterized by the onset of depression during the winter months, when there is less natural sunlight. Other recognized types of depression include psychotic depression (“with psychotic features”) and post-partum depression.

Physicians need to document the severity of psychiatric illness, especially whether it is “in remission” or not. A diagnosis of simply unspecified “depression” (in remission or not), even if described as severe, is considered a minor symptom.

However, a diagnosis of MDD (of any degree) has major severity-of-illness implications unless specified as “in remission” (asymptomatic). A symptomatic patient with MDD would not be considered in remission. A need for medication adjustments or psychiatric consult is also inconsistent with being “in remission.” Depression described as “acute” or “agitated” is assigned a code for MDD; documenting senile or vascular dementia with depression will also justify codes with the same severity of illness as MDD.

Bipolar disorder

Bipolar disorder, also called manic-depressive illness, is not as common as major depression or persistent depressive disorder. Bipolar disorder is characterized by cycling mood changes from extreme highs (mania) to extreme lows (depression). According to the DSM-V, bipolar I is defined by manic or mixed manic-depressive episodes that last at least 7 days, or by manic symptoms severe enough to require hospitalization. Usually, depressive episodes occur as well, typically lasting 2 weeks or more. Bipolar II is defined by a pattern of depressive and hypomanic episodes less severe than with type I. Bipolar disorder may be classified as mild, moderate, or severe (which includes psychotic features).

Coding guidelines treat documentation of bipolar disorder much the same as depression. For correct coding to reflect severity, bipolar disorder must be specifically documented as type I or type II and as having manic, depressed, or mixed (manic-depressive) symptomatic features. Simply stating a diagnosis of bipolar disorder (without type) or not including the symptomatic features is insufficient. As with depression, a diagnosis of bipolar disorder type I or II of any degree has major severity-of-illness implications unless documented as in remission (asymptomatic).


Schizophrenia is typically diagnosed (DSM-V) when a patient exhibits 2 or more characteristic symptoms during most of 1 month with persistence over at least 6 months, associated with social dysfunction: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms (i.e., diminished emotional expression, amotivational).

For correct coding, documentation should identify whether the patient's schizophrenia is chronic or an acute exacerbation. Schizophrenia has been clinically categorized into many subtypes, each of which have unique codes, but all of which have essentially the same impact on coding the severity of illness. For example, unspecified, catatonic type, and latent type all contribute significantly to severity-of-illness classification. Documentation of the specific subtype is encouraged but not required.

As with MDD and bipolar disorder, documentation of the status of schizophrenia as in remission (asymptomatic) results in a code without significant severity.