Q: “I have a question about depression and suicidal ideation. Should I code depression first and then suicide?”
A: That’s a great question. When we start looking at the ICD 10 guidelines, funny enough, there is not a specific directive as to which one has to go first. If you look these two codes up in ICD-10- CM, the depression code in ICD-9 remember we had that generic code for depression not otherwise specified, it was a 311? In ICD-10, they did away with that depression not otherwise specified, and it now maps to major depressive disorder, single episode, that’s where that goes, so it’s an F32.9.
VIDEO: Sequencing of Codes — Depression and Suicidal Ideation Codes
The suicidal ideation is a sign or a symptom code. It goes to R45.851. Some people go, “Isn’t suicidal ideation a sign or a symptom of depression?” No. Not everyone that is depressed becomes suicidal. That’s why you do want to code them separately when a patient has both, and when it’s documented that the patient has both in their record. But there is not anything in the guidelines that says one has to go in front of the other; instead the guideline that we fall back to is how do we define our principal diagnosis or a first-listed diagnosis?
The difference between those two being principal diagnosis is what we use in the facility setting, in the hospital, they call it a principal diagnosis. In the outpatient environment, we call it the first-listed diagnosis. They both have the same definition, and that definition is that condition, after study, to be chiefly responsible for the services rendered.
So, in determining which one of these goes first, you got to ask yourself, “Why did we wind up seeing the patient that day?” Well, we’re seeing them because they were depressed and during the course of treatment figured out that they do have some suicidal ideation because that’s typical questions that they ask. If you got a patient that’s coming in that’s depressed, we’re going to put them through a questionnaire and we’re going to ask them:
- “Are you having any suicidal ideation?
- Do you ever think about hurting yourself?”
- And if they say, “Yes,” “OK, do you have a plan?” because we need to know how far we need to escalate this, how important, how risky are you to yourself and to others.
- And the order of the diagnosis would be, “OK, what did you really wind up seeing them for?”
If they’re hospitalized – and I’m going to use principal diagnosis first –if they’re hospitalized for say a week and it’s because they’re depressed and while they’re depressed we ascertain that they had some suicidal ideation, but they don’t have plans, we don’t think they’re really going to act on it, but it’s important they let us know that. The main reason we saw them was because they were depressed; the depression code would go first.
Conversely, if they present and they’re being brought in or they’re presenting themselves to be evaluated because “I’ve been depressed for a while but now I’m having suicidal thoughts and I’m actually starting to work out a plan in my head.” In that situation, why are we seeing them? Well, yeah, they’re depressed but we’re seeing them because acutely they are suicidal and we need to get that addressed and help them overcome that.
So, the answer to this question about which one has to go first between depression and suicidal ideation is it depends on what the circumstances of that encounter were – why were they there? Were they there for the depression or were they there for the suicidal ideation because that will determine which one goes first.
The answer sheet just includes all of the definitions from the guidelines where I show you. And if both situations, maybe the depression and the suicidal ideation are both responsible for the patient being there or equally responsible, then according to the guidelines it doesn’t matter which one goes first and its typically not going to be a payment difference either. They’re both considered medically necessary in most or all situations.
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