ICD-10 Coding for Bipolar Disorder with Depression(F31.3, F31.4, F31.5)
Complete ICD-10-CM coding and documentation guide for Bipolar Disorder with Depression. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bipolar Disorder with Depression
F31.3-F31.5Primary Range
Bipolar disorder, current episode depressed
These codes are used to classify bipolar disorder when the current episode is depressive, with varying severity and presence of psychotic features.
Bipolar II disorder
Used for Bipolar II disorder, which involves hypomanic and depressive episodes.
Bipolar disorder, unspecified
Used when the specifics of the bipolar disorder episode are not documented.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| F31.3 | Bipolar disorder, current episode depressed, mild or moderate | Use when the depressive episode is mild or moderate without psychotic features. |
|
| F31.4 | Bipolar disorder, current episode depressed, severe, without psychotic features | Use when the depressive episode is severe without psychotic features. |
|
| F31.5 | Bipolar disorder, current episode depressed, severe, with psychotic features | Use when the depressive episode is severe with psychotic features. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for bipolar with depression
Essential facts and insights about Bipolar Disorder with Depression
Primary ICD-10-CM Codes for bipolar with depression
Decision Criteria
clinical Criteria
- Presence of depressive symptoms with mild or moderate severity
Applicable To
- Mild depressive episode
- Moderate depressive episode
Excludes
- Major depressive disorder (F32-F33)
Clinical Validation Requirements
- Documentation of depressive symptoms with mild or moderate severity
- PHQ-9 score indicating mild to moderate depression
Code-Specific Risks
- Incorrectly coding severe episodes as mild or moderate
Coding Notes
- Ensure documentation specifies the severity of the depressive episode.
F31.4 - Bipolar disorder, current episode depressed, severe, without psychotic features
Use when the depressive episode is severe without psychotic features.
Applicable To
- Severe depressive episode without psychosis
Excludes
- Major depressive disorder (F32-F33)
Clinical Validation Requirements
- Documentation of severe depressive symptoms
- PHQ-9 score indicating severe depression
Coding Notes
Ensure severity is clearly documented.
F31.5 - Bipolar disorder, current episode depressed, severe, with psychotic features
Use when the depressive episode is severe with psychotic features.
Applicable To
- Severe depressive episode with psychosis
Excludes
- Major depressive disorder (F32-F33)
Clinical Validation Requirements
- Documentation of severe depressive symptoms with psychotic features
- PHQ-9 score indicating severe depression
Coding Notes
Psychotic features must be explicitly documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Major depressive disorder, recurrent, mild
F33.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bipolar Disorder with Depression to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code F31.3.
Impact
Clinical: May lead to inappropriate treatment., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials or reduced reimbursement.
Mitigation Strategy
Ensure thorough psychiatric evaluation and documentation., Use checklists to confirm all symptoms are recorded.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Violates ICD-10 coding guidelines., Data Quality: Leads to inaccurate clinical data.
Mitigation Strategy
Use only the bipolar disorder code as per Excludes1 notes.
Impact
Reimbursement: May affect DRG assignment and payment., Compliance: Non-compliance with specificity requirements., Data Quality: Reduces the accuracy of health records.
Mitigation Strategy
Query for specifics or use the most specific code available.
Impact
Using unspecified codes when specific details are available.
Mitigation Strategy
Implement regular training on documentation requirements and coding specificity.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Bipolar Disorder with Depression, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bipolar Disorder with Depression
Use these documentation templates to ensure complete and accurate documentation for Bipolar Disorder with Depression. These templates include all required elements for proper coding and billing.
Patient with severe bipolar depression without psychotic features
Specialty: PsychiatryRequired Elements
- Diagnosis
- Current Episode
- Symptoms
- PHQ-9 Score
- Treatment Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Bipolar Disorder with Depression? Ask your questions below.