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ICD-10 Guide
ICD-10 CodesF31.78

F31.78

Billable

Bipolar disorder, in full remission, most recent episode mixed

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 F31.78 is a billable code used to indicate a diagnosis of bipolar disorder, in full remission, most recent episode mixed.

Key Diagnostic Point:

F31.78 refers to a specific diagnosis of bipolar disorder where the patient is currently in full remission following a mixed episode. In bipolar disorder, individuals experience extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). A mixed episode is characterized by symptoms of both mania and depression occurring simultaneously or in rapid succession. Full remission indicates that the patient is not currently experiencing any significant symptoms of the disorder. This state can be achieved through effective treatment, which often includes mood stabilizers, psychotherapy, and lifestyle modifications. It is crucial for healthcare providers to monitor patients for any signs of relapse, as individuals with bipolar disorder are at an increased risk for suicide, particularly during depressive episodes. Regular assessments of mood, behavior, and overall mental health are essential to ensure ongoing stability and to adjust treatment plans as necessary.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between episodes of mania, hypomania, and depression.
  • Understanding the criteria for full remission versus partial remission.
  • Recognizing the nuances of mixed episodes in bipolar disorder.
  • Documenting the patient's treatment history and response to medications.

Audit Risk Factors

  • Inadequate documentation of remission status.
  • Failure to document the most recent episode type.
  • Lack of comprehensive treatment history.
  • Insufficient assessment of suicide risk.

Specialty Focus

Medical Specialties

Psychiatry

Documentation Requirements

Detailed clinical notes on mood assessments, treatment plans, and patient history.

Common Clinical Scenarios

Patients presenting with mood instability, medication management, and therapy sessions.

Billing Considerations

Ensure thorough documentation of remission status and any changes in treatment.

Primary Care

Documentation Requirements

Regular mental health screenings and documentation of any referrals to mental health specialists.

Common Clinical Scenarios

Routine check-ups for patients with a history of bipolar disorder.

Billing Considerations

Monitor for signs of relapse and ensure appropriate follow-up care.

Coding Guidelines

Inclusion Criteria

Use F31.78 When
  • According to ICD
  • 10 guidelines, F31
  • 78 should be used when the patient has a documented history of bipolar disorder and is currently in full remission
  • Documentation must support the diagnosis, including the absence of significant symptoms and the most recent episode type

Exclusion Criteria

Do NOT use F31.78 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

90834CPT Code

Psychotherapy, 45 minutes with patient

Clinical Scenario

Used during therapy sessions for patients in remission to maintain mental health.

Documentation Requirements

Document the focus of therapy and patient progress.

Specialty Considerations

Psychiatrists should ensure that therapy notes reflect the patient's remission status.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of bipolar disorder, including remission states, which aids in better tracking of patient outcomes and treatment efficacy.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of bipolar disorder, including remission states, which aids in better tracking of patient outcomes and treatment efficacy.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of bipolar disorder, including remission states, which aids in better tracking of patient outcomes and treatment efficacy.

Resources

Clinical References

  • •
    American Psychiatric Association - Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

Coding & Billing References

  • •
    American Psychiatric Association - Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

Frequently Asked Questions

What does 'in full remission' mean in the context of bipolar disorder?

In full remission means that the patient is currently not experiencing any significant symptoms of bipolar disorder, indicating effective management of the condition.