F31.70

Bipolar disorder, currently in remission, unspecified

Bipolar disorder, currently in remission, unspecified (F31.70) describes a clinical state where a patient with a confirmed history of bipolar disorder (type I or II) no longer meets the full symptomatic criteria for a manic, hypomanic, or major depressive episode. This code is specifically applied when the clinical documentation fails to specify whether the remission is 'partial' (residual symptoms present without meeting full episode criteria) or 'full' (complete absence of significant symptoms), and does not identify the polarity of the most recent mood episode. Effective management during this phase focuses on maintenance pharmacotherapy—often involving mood stabilizers like lithium or anticonvulsants—and psychotherapy to prevent relapse. Clinical surveillance remains necessary, as individuals in remission remain at high risk for future affective recurrence triggered by stressors, sleep disruption, or medication non-adherence.

Clinical Symptoms

Absence of active manic symptoms (e.g., pressured speech, grandiosity)
Absence of active depressive symptoms (e.g., anhedonia, suicidal ideation)
Stable or euthymic mood state
Return to baseline social and occupational functioning
Restored sleep-wake cycles
Potential residual sub-syndromal anxiety
Maintenance of cognitive focus and concentration
Adherence to long-term mood-stabilizing medication regimens

Common Causes

Genetic predisposition and family history of mood disorders
History of neurotransmitter dysregulation (dopamine, serotonin, norepinephrine)
Past structural or functional brain alterations in the prefrontal cortex and amygdala
Effective clinical response to maintenance pharmacotherapy (Lithium, Valproate, Lamotrigine)
Successful management of psychosocial stressors
Regularity in circadian rhythms and sleep hygiene
Engagement in ongoing cognitive behavioral therapy or psychoeducation

Documentation & Coding Tips

Distinguish between Full and Partial Remission status to ensure clinical accuracy.

Example: Patient with Bipolar I disorder, most recent episode manic, presents for maintenance check. Current status is in full remission with no mood symptoms for 8 months. Assessment: Bipolar disorder, in remission, unspecified (F31.70). Maintenance therapy with Lithium 600mg BID continued. HCC status: Patient remains stable on pharmacotherapy but requires ongoing monitoring for chronic mental health stability.

Billing Focus: Documentation should clearly state that no symptoms of a manic or depressive episode are currently present to justify the remission status code.

Document the maintenance medication regimen to support the diagnosis and the complexity of medical decision making.

Example: Stable on Lamotrigine 200mg daily. No evidence of rapid cycling or mixed features. The patient has been euthymic for over one year. Plan: Continue current dosage, monitor serum levels next visit. Bipolar disorder, currently in remission, unspecified (F31.70). This supports a moderate level of complexity for medical decision making based on the management of a chronic condition.

Billing Focus: Identify the specific medication and the frequency of monitoring to support E/M level selection.

Specify the lack of symptoms such as pressured speech, insomnia, or suicidal ideation.

Example: Psychiatric Review of Systems: Negative for flight of ideas, grandiosity, or psychomotor agitation. Negative for anhedonia or hopelessness. Patient is currently in remission (F31.70). Employment is stable and social interactions are appropriate. This specificity confirms the diagnosis and eliminates the need for an acute-phase code.

Billing Focus: Reporting the absence of symptoms justifies why an acute code (e.g., F31.11) was not used, reducing audit risk.

Incorporate the longitudinal history of the disorder while coding for the current state.

Example: History of Bipolar II with last hypomanic episode 2 years ago. Currently euthymic on Quetiapine. Diagnosis: Bipolar disorder, currently in remission, unspecified (F31.70). Patient has no active psychiatric symptoms but history warrants high-intensity monitoring. Risk Adjustment: Bipolar disorder remains a persistent risk even in remission, influencing overall health complexity.

Billing Focus: Clinical history provides context for the medical necessity of the visit despite the lack of acute symptoms.

Explicitly state when the last episode occurred to support the unspecified nature of the remission code if the exact type is not documented.

Example: Follow up for Bipolar disorder. Last episode was 14 months ago; patient cannot recall if symptoms were primarily manic or depressive at onset. Current state: Remission (F31.70). No mood disturbances noted during mental status exam. Maintenance plan: Monthly counseling and medication adherence check.

Billing Focus: Using F31.70 is appropriate when the provider documentation does not specify if the last episode was manic, hypomanic, or depressive.

Relevant CPT Codes

99212 - Office or other outpatient visit for the evaluation and management of an established patient
Used for very stable patients in remission requiring minimal medication adjustments or simple follow-up.
99213 - Office or other outpatient visit for the evaluation and management of an established patient
Standard code for a routine follow-up of a stable bipolar patient in remission with low complexity management.
99214 - Office or other outpatient visit for the evaluation and management of an established patient
Appropriate when managing a patient in remission who has multiple comorbidities or requires significant medication monitoring (e.g., Lithium levels).
90833 - Psychotherapy, 30 minutes with patient when performed with an evaluation and management service
Used when the provider provides both medication management and therapeutic intervention to maintain remission.
90836 - Psychotherapy, 45 minutes with patient when performed with an evaluation and management service
Used for longer therapeutic sessions aimed at relapse prevention in bipolar patients.
80178 - Lithium, therapeutic drug monitoring
Essential for monitoring patients in remission who utilize Lithium as a mood stabilizer.
99406 - Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
Bipolar patients have higher rates of nicotine dependence; cessation is part of holistic maintenance.
90863 - Pharmacologic management, including prescription and review of medication, when performed with psychotherapy
Used by prescribing psychologists in certain jurisdictions for managing bipolar medications.
99358 - Prolonged evaluation and management service before and/or after direct patient care
Used for extensive review of psychiatric records or coordination of care for patients with complex histories of bipolar disorder.
96127 - Brief emotional/behavioral assessment
Used for screening tools (e.g., PHQ-9 or MDQ) to objectively confirm remission status.