Documentation and Coding for Bipolar, Delusional & Personality Disorders

January 11, 2023

Claims & Coding Medical Policy & Clinical Guidelines

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. Bipolar II disorder is a separate diagnosis from Bipolar I disorder
	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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