Depression diagnosis uses ICD-10 F32.x (single episode) or F33.x (recurrent major depressive disorder). Treatment includes depression screening (CPT 96127 for PHQ-9), psychotherapy codes (90834, 90837), medication management (E/M codes 99213-99215), and collaborative care model (99492-99494). PHQ-9 score at baseline and follow-up visits documents treatment response. All depression treatment requires documentation of functional impairment and medical necessity.
Always include severity modifier: F32.0/F33.0 (mild), F32.1/F33.1 (moderate), F32.2/F33.2 (severe without psychosis), F32.3/F33.3 (severe with psychosis). Bill CPT 96127 for depression screening (PHQ-9, PHQ-8) when screening is a primary service. Psychotherapy uses time-based codes (90832, 90834, 90837). Medication management uses E/M codes (99213-99215). Do not bill screening and E/M on the same date for the same condition without modifier 25 or documenting distinct services. Collaborative care requires primary care provider involvement and psychiatry oversight.
Most payers require prior authorization for ongoing psychotherapy and medication management. Session limits vary (20-30 sessions annually). Depression screening (96127) is often covered without authorization under preventive care guidelines. Some plans reimburse collaborative care without session limits. Medicare covers depression screening annually. Verify payer policies on screening frequency and therapy limits before treatment planning.
Use modifier 25 if billing E/M and psychotherapy on the same date. Do not bill screening (96127) and E/M on the same date without modifier 25 unless the screening is included in the E/M assessment. Collaborative care codes (99492-99494) stand alone; do not bill with psychotherapy or individual E/M codes when billing collaborative care. Modifier 95 indicates telehealth for all depression-related codes.
Document PHQ-9 score at initial assessment and follow-up visits to track treatment response. Include baseline functional impairment (work, social, home functioning). For psychotherapy: document therapeutic interventions and progress toward symptom reduction. For medication management: document medications, dosages, side effects, efficacy, and patient adherence. For collaborative care: document coordination with primary care provider and psychiatry involvement. Document suicidal/homicidal risk assessment as clinically indicated.
F32.x = major depressive disorder (single episode); F33.x = recurrent. Severity: .0 (mild), .1 (moderate), .2 (severe without psychosis), .3 (severe with psychosis).
Yes. CPT 96127 covers depression screening. Billed separately from E/M or therapy when appropriate. Medicare allows billing when medically necessary.
Collaborative care codes: 99492 (initial), 99493 (subsequent), 99494 (additional 30 min). For primary care-based depression management with psychiatry oversight.
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