Psychiatry Coding & Reimbursement Alert

Hint: You will now have added code choices when your clinician identifies hypomania.

When your clinician arrives at a diagnosis of bipolar disorder, you will need to first focus on whether the most recent episode is manic, depressive, or mixed. Additionally, you will need to focus on the severity of symptoms, presence or absence of psychotic behavior. You will also need to check if the condition is in remission. 

ICD-9: When your clinician diagnoses a bipolar disorder with the current episode as manic, you’ll have to first base your reporting of the diagnosis on whether the episode represents a single manic episode (296.0x, Bipolar I disorder, single manic episode) or a current episode in a circular type of Bipolar I disorder with a previous attack of depression (296.4x, Bipolar I disorder, most recent episode [or current] manic). Both codes further expand with a 5th digit based on severity of symptoms, presence or absence of psychotic behavior, and whether or not the condition is in remission.

So, the ICD-9 code, 296.4 expands using a fifth digit into the following seven codes:

• 296.40 (Bipolar I disorder, most recent episode [or current] manic, unspecified)
• 296.41 (Bipolar I disorder, most recent episode [or current] manic, mild)
• 296.42 (Bipolar I disorder, most recent episode [or current] manic, moderate)
• 296.43 (Bipolar I disorder, most recent episode [or current] manic, severe, without mention of psychotic behavior)
• 296.44 (Bipolar I disorder, most recent episode [or current] manic, severe, specified as with psychotic behavior)
• 296.45 (Bipolar I disorder, most recent episode [or current] manic, in partial or unspecified remission)
• 296.46 (Bipolar I disorder, most recent episode [or current] manic, in full remission)

As noted, the ICD-9 code, 296.4x includes circular type mania if there was a previous attack of depression. However, you cannot use 296.4x if your clinician’s diagnosis is brief compensatory or rebound mood swings. In such a case, you will have to report this diagnosis with 296.99 (Other specified episodic mood disorder).

ICD-10: When you begin using ICD-10 codes, you will have to report only one set of codes for bipolar disorder with the current episode manic (i.e. other than a single manic episode). You start your reporting in ICD-10 with F31 (Bipolar disorder).But again, as in ICD-9, you will have to use further expansion to F31 to identify the severity and presence or absence of psychotic symptoms and to report the condition in remission.

The three code choices that F31 will expand into when the current episodes are manic include:

• F31.0 (Bipolar disorder, current episode, hypomanic)
• F31.1 (Bipolar disorder, current episodemanic without psychotic features)
• F31.2 (Bipolar disorder, current episodemanic severe with psychotic features, unspecified)

Depending on the severity of symptoms, F31.1 expands into the following four codes:

• F31.10 (Bipolar disorder, current episodemanic without psychotic features, unspecified)
• F31.11 (Bipolar disorder, current episodemanic without psychotic features, mild)
• F31.12 (Bipolar disorder, current episodemanic without psychotic features, moderate)
• F31.13 (Bipolar disorder, current episodemanic without psychotic features, severe)

If the condition is in remission with the most recent episode manic, you will have to choose another set of codes based on the extent of remission. You report this with F31.7- (Bipolar disorder, currently in remission). Based on the whether the condition is in partial or full remission, F31.7 expands into the following codes when the most recent episode was in some way manic: 

• F31.71 (Bipolar disorder, in partial remission, most recent episode hypomanic)
• F31.72 (Bipolar disorder, in full remission, most recent episode hypomanic)
• F31.73 (Bipolar disorder, in partial remission, most recent episode manic)
• F31.74 (Bipolar disorder, in full remission, most recent episode manic)

Reminder: You cannot use F31.- when your psychiatrist diagnoses bipolar disorder, single manic episode (F30.-); major depressive disorder, single episode (F32.-); or major depressive disorder, recurrent (F33.-).

Brush up on These Basics Briefly

Documentation spotlight: Your psychiatrist will arrive at a diagnosis of bipolar disorder with current episode manic based on a complete history and a complete evaluation of the patient. Your psychiatrist will perform a complete mental status examination, a complete psychiatric and medical history of the patient and family, and a review of systems.

Some of the findings that your clinician would most likely record in a patient with bipolar disorder with current episodemanic include grandiosity, excessive speech, reduced necessity of sleep, feeling distracted, racing thoughts, deep and intense focus on any activity, and taking part in dangerous activities that fetch immense pleasure and pain.

Upon examination, your psychiatrist might note that the patient lacks proper personal appearance and that the patient’s clothes appear disorganized (not color coordinated), although these patients generally prefer wearing vibrant and vivid clothing. Your clinician might also note that the patient appears joyous and hyperactive and has the tendency to speak very fast.

The patient will generally be having grandiose thoughts and might be, in many cases, delusional. They also suffer from suicidal and homicidal tendencies, and your clinician will try to assess a patient for these tendencies, as it might need emergency intervention.

Tests: Your clinician might order many lab tests if he suspects a diagnosis of bipolar disorder. Many of these tests are aimed at confirming whether or not some other associated condition exists that might be producing similar symptoms. In addition, some of these tests will help assess the patient’s general health condition as this might be vital to plan therapy.

Some of the tests that your clinician might order in a patient with suspicion of a diagnosis of bipolar disorder include complete blood count, electrolyte concentrations, ESR, kidney function tests, and tests for hormonal counts to assess the functioning of the thyroid. Your psychiatrist will also ask for a urinalysis to assess for substance abuse.

Apart from these tests, your clinician might also ask for other diagnostic tests such as an MRI scan, ECG, and EEG, again to rule out other conditions and to assess the patient for future pharmacological and therapeutic interventions.

The immediate care planning will include assessment of the patient for suicidal or homicidal tendencies that might require rapid attention and crisis psychotherapy. At later dates, your clinician might include psychotherapy and group therapy. He might also opt for concurrent medication with antipsychotics or benzodiazepines. Some patients have also benefited from other forms of therapy, such as electroconvulsive therapy.