A county behavioral health inpatient unit’s psychiatrist documents major depressive disorder, single episode, severe, without psychotic features. Which approach correctly reflects diagnosis coding expectations?

Mental-health diagnosis coding on a county behavioral health inpatient unit follows the psychiatrist’s documented specificity—episode type, severity, and psychotic-feature status—when those elements are stated. Major depressive disorder, single episode, severe, without psychotic features should be coded to reflect that documented detail because ICD-10-CM mental-health categories are built on precisely those axes. Capturing the psychiatrist’s specificity supports appropriate severity reporting for public behavioral-health programs without inventing psychosis or collapsing to unspecified depression.

Coding only “depression, unspecified” because “behavioral health never uses episode or severity detail” fails by concept: the classification expects and rewards documented specificity; discarding it understates clinical severity. Coding schizophrenia whenever depression is severe, even when psychosis is explicitly excluded, fails because severity of depression is not equivalent to a schizophrenia diagnosis and contradicts documented absence of psychotic features. Using the nursing mood score alone to select the ICD-10-CM subcategory fails because standardized nursing scores inform care but are not a substitute for the psychiatrist’s diagnostic statement.

Exam caveat: do not infer psychotic features, recurrent versus single episode, or remission status without provider documentation; likewise, do not ignore specificity the psychiatrist already provided. Operational check: abstract episode, severity, and feature qualifiers exactly from psychiatry documentation; confirm consistency across admission note and discharge summary; query only for missing or conflicting axes that prevent accurate code selection, not to overwrite clear psychiatric documentation.