Wiki ICD 10 code for Bipolar Disorder Type 1 most recent episode depressed

[Cindy Elliott]

When the severity is not documented within the chart note and it is part of the description of the ICD 10 code ex (Bipolar disorder type 1, most recent episode depressed )would you default to the unspecified code? What code would you use for Bipolar disorder type 1, most recent episode depressed?
F31.30 or F31.9.

 

[mitchellde]

Part of ICD-10 CM is the specificity of the diagnosis. And that means we need to prompt the providers into documenting conditions more completely in the medical record. Not documented as mild or moderate I would go with F31.30. Having said this, you will need to be prepared to appeal claims that use unspecified dx codes. Using the not documented issue will not be an argument to get the claim paid. If the provider cannot be specific the why not?