Name of the Condition

• Common name: Bipolar Disorder
• Medical term: Bipolar disorder, current episode mixed, severe, with psychotic features
• ICD-10 Code: F31.64

Summary

Bipolar disorder is a mental health condition characterized by extreme mood swings. The "mixed" episode features simultaneous symptoms of mania and depression, which can be severe and include psychotic symptoms such as hallucinations or delusions.

Causes

• Genetic predisposition plays a significant role, with a higher risk in individuals with a family history of bipolar disorder.
• Neurochemical imbalances in the brain.
• Environmental stressors and traumatic experiences can trigger episodes.

Risk Factors

• Family history of bipolar disorder or other mental health conditions.
• Periods of high stress or major life changes.
• Substance abuse, which can exacerbate symptoms.

Symptoms

• Cognitive disturbances like rapid, disorganized thinking.
• Simultaneous symptoms of mania (e.g., increased energy, decreased need for sleep) and depression (e.g., hopelessness, lack of interest).
• Psychotic features may include hallucinations or delusions.

Diagnosis

• Psychiatric evaluation and detailed medical history.
• Mood charting to track mood variations over time.
• Exclusion of other potential causes through medical tests.

Treatment Options

• Medications: Mood stabilizers (e.g., lithium), antipsychotics, and antidepressants to manage symptoms.
• Psychotherapy: Cognitive-behavioral therapy (CBT) for coping strategies.
• Electroconvulsive therapy (ECT) in severe cases where medication is ineffective.

Prognosis and Follow-Up

• Prognosis varies; symptoms can be managed with regular treatment.
• Long-term outlook improves with adherence to treatment and regular psychiatric follow-up.
• Regular monitoring to adjust treatment plans as needed.

Complications

• Social and occupational impairment.
• Increased risk of substance abuse.
• Higher risk of suicidal thoughts or behaviors if untreated.

Lifestyle & Prevention

• Healthy lifestyle changes: Regular exercise, balanced diet, consistent sleep schedule.
• Stress management techniques, like mindfulness or yoga, to reduce triggers.
• Avoid substance abuse to minimize exacerbation of symptoms.

When to Seek Professional Help

• Sudden or severe mood changes that impact daily life.
• Experiencing psychotic symptoms or suicidal thoughts.
• If current medication becomes ineffective or side effects become unmanageable.

Additional Resources

• National Alliance on Mental Illness (NAMI)
• Mental Health America (MHA)
• International Bipolar Foundation

Tips for Medical Coders

• Ensure specificity by noting the current mixed episode with severity and psychotic features in documentation.
• Use F31.64 to accurately code this condition, avoiding confusion with similar but distinct codes.
• Double-check accompanying documentation to support coding accuracy and avoid common errors such as omitting the severity or psychotic features.