Documentation and Coding for Bipolar, Delusional & Personality Disorders
A quick reference guide to assist with accurate, complete documentation and coding that reflects the true nature of a patient’s current health status at the highest level of specificity.
Per ICD-10 official guidelines for reporting and coding, “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”
Documentation & Coding Tips
Documentation needs to be clear and detailed using the following terms to allow accurate ICD10 code selection.
Specificity:
- Episode: current or most recent
- State: hypomanic, manic, depressed, or mixed
- Severity: mild, moderate, severe, severe with psychotic features
- Status: partial remission, full remission
Disorder | ICD 10 Code | ICD 10 Description | Description of Condition |
|---|---|---|---|
Bipolar | F31.X | Bipolar I | Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). |
F31.81 | Bipolar II | Has had at least one major depressive episode and at least one hypomanic episode but has never had a manic episode. | |
F31.9 | Bipolar disorder, unspecified |
| |
Delusional & Personality Disorders | F22 | Delusional | A delusion is a strongly held belief in something that can be proven not to be true or can be proven to be exaggerated even though the belief may have some basis. Delusions may revolve around a variety of themes, paranoia being the most common. |
F60.0 | Paranoid | Characterized by excessive distrust and suspicion of others, even those they are very close to, to such an extreme that it is hard to form close relationships & tend to withdraw from others. | |
F60.1 | Schizoid | A disorder in which people avoid social activities and interacting with others. | |
F60.2 | Antisocial | Characterized by disregard for other people including impulsive, irresponsible, and often criminal behavior. | |
F60.3 | Borderline | Characterized by unstable moods, behavior, and relationships. | |
F60.4 | Histrionic | Condition that affects the way a person thinks, perceives, and relates to others. | |
F60.5 | Obsessive-compulsive | Characterized by excessive orderliness, perfectionism, attention to details, and a need for control in relating to others. | |
F60.6 | Avoidant | Characterized by social discomfort and avoidance of interpersonal contact. | |
F60.7 | Dependent | People with DPD often feel helpless, submissive, or incapable of taking care of themselves. They may have trouble making simple decisions. | |
F60.81 | Narcissistic | A disorder in which a person has an inflated sense of self-importance. | |
F60.89 | Other specified Personality disorder | Eccentric personality, Immature personality, Passive-aggressive personality, Self-defeating personality disorders | |
F60.9 | Personality disorder, unspecified | Character disorder NOS, Character neurosis NOS, Pathological personality NOS |
References:
- www.psychiatry.org - American Psychiatric Association – Depression
- www.encoderprofp.com - Optum 360 – Encoder Pro – Major Depression
- ICD-10 –CM 2022 “The Complete Official Codebook”
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