Z01.411 - Encounter for gynecological examination (general) (routine) with abnormal findings

Clinical Definition

A Major Depressive Disorder (MDD) episode of mild severity is characterized by a persistent depressed mood or loss of interest/pleasure in activities, accompanied by other symptoms, that cause clinically significant distress but with relatively mild functional impairment.

Documentation Requirements

• Duration of symptoms (at least 2 weeks)

• Severity must be explicitly stated as "mild"

• At least 5 of the following symptoms:

  • Depressed mood

  • Diminished interest/pleasure

  • Weight/appetite changes

  • Sleep disturbance

  • Psychomotor changes

  • Fatigue/energy loss

  • Worthlessness/guilt

  • Concentration difficulties

  • Suicidal ideation

• Episode number (single vs. recurrent)

• Remission status (if applicable)

• Functional impact assessment

Common Synonyms

• "Depression"

• "Feeling down"

• "The blues"

• "Low mood"

• "Not feeling like myself"

Coding Conflicts

Excludes1:

• Bipolar disorder (F31.-)

• Mood disorder due to known physiological condition (F06.3)

• Adjustment disorder with depressed mood (F43.21)

Excludes2:

• Dysthymia (F34.1)

• Premenstrual dysphoric disorder (F32.81)

Scribing.io Automation

Scribing.io's AI automatically:

• Identifies depression-related keywords in patient narratives

• Tags severity indicators ("mild," "some," "slight")

• Maps symptom descriptions to diagnostic criteria

• Tracks episode duration through visit documentation

• Flags potential conflicts with other mood disorders

• Prompts for missing documentation elements needed for code specificity