Guest post: Depression versus bipolar disorder

by Brandi Hutcheson, RN, MSN, CCM, CCDS

More than once, I have observed providers document both depression and bipolar disorder together. Although these diagnoses share similarities, they are not interchangeable.

According to the American Psychiatric Association (APA) website, depression is defined as a common, but serious medical diagnosis that affects the way a patient feels, thinks, and acts. It causes “feelings of sadness and/or a loss of interest in activities once enjoyed.” If gone untreated, depression can cause a number of emotional and physical problems and limit an individual’s ability to function in every day life and work.

While symptoms of depression can range from mild to severe, the APA lists the following potential symptoms:  

• Feeling sad or having a depressed mood
• Loss of interest or pleasure in activities once enjoyed
• Changes in appetite (weight loss or gain unrelated to dieting)
• Trouble sleeping or sleeping too much
• Loss of energy or increased fatigue
• Increase in purposeless physical activity or slowed movements and speech
• Feeling worthless or guilty
• Difficulty thinking, concentrating, or making decisions
• Thoughts of death or suicide

In order to be diagnosed with depression, a patient’s symptoms must last at least two weeks.

Bipolar disorders, on the other hand, are brain disorders that cause changes in a person’s mood, energy and their ability to function, according to the APA. There are three different conditions that fall under bipolar disorders: bipolar I, bipolar II, and cyclothymic disorder.

People suffering from bipolar disorders experience “mood episodes,” categorized as manic, hypomanic, or depressive. Generally, patients with bipolar disorders have periods of normal moods as well.

During a manic episode, the patient will be high spirited or irritable to the extreme for most of the day for most of the days during at least a weeklong period. The patient will have more energy than usual and experience at least three of the following:

• Exaggerated self-esteem or grandiosity
• Less need for sleep
• Talking more than usual, talking loudly and quickly
• Easily distracted
• Doing many activities at once, scheduling more events in a day than can be accomplished
• Increased risky behavior
• Uncontrollable racing thoughts or quickly changing ideas or topics

A hypomanic episode is similar to a manic one, but the symptoms are less severe and they only last for four days in a row. Hypomanic symptoms don’t lead to the major problems that mania often causes. The patient is generally still able to function during these periods.

A major depressive episode is a period of two weeks in which a person has at least five of the following symptoms, including at least one of the first two items on the list:

• Intense sadness or despair; feeling helpless, hopeless, or worthless
• Loss of interest in activities once enjoyed
• Feeling worthless or guilty
• Sleep problems
• Feeling restless or agitated or slowed speech or movements
• Changes in appetite
• Loss of energy, fatigue
• Difficulty concentrating, remembering making decisions
• Frequent thoughts of death or suicide

     A more thorough description of mania and hypomania is available from Amen Clinics. According to Amen Clinics, mania and hypomania are characterized by a “heightened sense of physical and mental energy.” Both states may include the following symptoms:

• Abnormally elevated mood bordering on euphoria
• Inflated self-esteem
• High energy levels
• Decreased need for sleep
• Increase in goal-oriented activity
• Grandiose notions, ideas, or plans
• Increased talking or pressured speech
• Racing thoughts
• Hypersexuality
• Hyperreligiosity
• Excessive appetite
• Inappropriate or risky behavior
• Irritability or aggression

Amen Clinics also describes more serious symptoms of mania such as hallucinations, delusions, and paranoia, which may be seen in psychosis. These more serious symptoms, however, are not seen in hypomania.

It seems apparent that both depression and bipolar disorder are similar in the depressive episodes, and perhaps that is where providers get stuck. Review of patient home medication lists by physicians may not be revealing as to which diagnosis is accurate too. Depression and bipolar disorder can be treated by antidepressants, antipsychotics, and mood stabilizers alike. Conversely, bipolar disorder is not treated with antidepressants alone as they can trigger mania (See information published by Mayo Clinic).

When coding both diagnoses at the same time during an encounter, I have noticed a coding edit pops up in our encoder that states both depression and bipolar disorder cannot be coded simultaneously. As a CDI specialist, I wondered whether I should query about depression or bipolar disorder in order to arrive at the correct code.  

I found the answer to my question in the American Hospital Association (AHA) Coding Clinic, first quarter 2020, p. 23. The question asked, “what code is assigned when the patient is diagnosed with bipolar disorder and major depressive disorder recurrent, mild?”

The advice is to assign the code for bipolar disorder since it includes both depression and mania, and therefore, it’s more significant to code the bipolar disorder. I believe this information would hold true with unspecified depression as well. In my opinion, this information would be helpful for physician education, particularly for those providers who list both diagnoses in tandem.

Depression and bipolar disorder(s) have countless codes depending on the amount of specificity that the provider can document. These specific and nonspecific codes can result in the addition of a CC or a hierarchical condition category. These codes may also affect the severity of illness as well, according to the ACDIS Pocket Guide.

In conclusion, when and if there is both a diagnosis of depression and bipolar disorder documented, assign the code for bipolar disorder. Both codes are not welcome, so to speak. You could certainly query the bipolar disorder for greater specificity whenever the documentation is unclear.

Editor’s note: Hutcheson is a remote CDI specialist at Community Health Systems in Franklin, Tennessee. Contact her at brandi_hutcheson@chs.net. Opinions expressed are those of the author and do not necessarily reflect those of ACDIS, HCPro, or any of its subsidiaries.