bipoler versus borderline

[randomdoc1]

I have a patient, who I've gotten to know for nearly five months. Overtime, there was an enduring pattern of chronic interpersonal chaos, passive SI, emotional lability, and impulsivity. Not surprisingly, little response to medications. I initially started her on a low dose antidepressant. Early on, I suspected at the very least she'd benefit from DBT but she failed to follow-up on this and I did start her on some antipsychotic augmentation. At least it can serve both as a mood stabilizer and augment antidepressants if there's a differential of MDD, bipolar, or borderline. Not to say that people with borderline personality disorder cannot have bipolar disorder or other comorbidities. But, the chronicity and unrelenting course of her symptoms suggested her primary diagnosis was most likely borderline personality disorder. I broke the diagnosis to her, as I continued to emphasize DBT over this being a medication issue, she got upset and checked herself inpatient. I encouraged the inpatient doc to call me so I can help coordinate care. He didn't and slaps her with a "bipolar" diagnosis which she was much happier about (I feel like a lot of patients prefer this since they feel it puts more onus on the medication to do the work for them than pursuing something like DBT). Fortunately, the patient is not mad at me, but there is some idealization of this inpatient psychiatrist who told her she has bipolar after seeing her just once and not even consulting with me. She likes him so much she wants to follow up with him outpatient. It's actually a relief for me, and we'll see how accurate he thinks his diagnosis is after the ten thousandth call she's given him. She used to call me relentlessly.

But really, I just don't get it. Outpatient psychiatrist calls to help give information and yet the inpatient doc draws his own conclusion of bipolar disorder? I'm thinking wtf a little....my only beef with this is that it feels like one step back for the patient. Instead of pursuing DBT there is more enabling and less potential for real progress to be made. Oh well, won't be my case anymore but I admit I really don't like seeing delays in potential progress.

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[HarryMTieboutMD]

"rinse, repeat"

 

[Shikima]

Just remember, anyone with irritability and chronic suicidality is Bipolar. 🙄

 

[PistolPete]

Sorry OP. If I had a dollar for each time something like this happened to me, I'd be rich. All you can do is try your best. If the patient doesn't want to listen to your opinion, then that's her choice.

 

[st2205]

Sounds like the patient isn't quite ready for what you're offering. You may feel disappointed about a patient who calls you all the time declining what you feel is the best treatment, but it sounds like this other person picking them up is a rather palatable outcome.

/countertransference

 

[nexus73]

This won't really help now, but in my experience about 80% of the time if I give a patient with BPD an article explaining what it is, they immediately identify all of their symptoms and recognize it within themselves. The other 20% seem to be people with some mix of narcissistic PD, or actual BPD but aware enough they don't want the pejorative label.

 

[randomdoc1]

This won't really help now, but in my experience about 80% of the time if I give a patient with BPD an article explaining what it is, they immediately identify all of their symptoms and recognize it within themselves. The other 20% seem to be people with some mix of narcissistic PD, or actual BPD but aware enough they don't want the pejorative label.

Interesting! I usually do that and most people are understanding. The remaining who don't fully accept it fall in the category of what you describe. Another category are those who prefer to assume the pt role and want the meds to do the work. It reminds me a lot of the people who don't want CBT-I and keep insisting it is a med issue.

Nexus, which article do you usually use?

 

[randomdoc1]

Sounds like the patient isn't quite ready for what you're offering. You may feel disappointed about a patient who calls you all the time declining what you feel is the best treatment, but it sounds like this other person picking them up is a rather palatable outcome.

/countertransference

Lol. I personally try to exercise good bedside manner, answer my calls promptly, etc. I have some luxuries as I have a private practice. This particular pt is new to getting psychiatric care. She'll see a new doc who is in a big healthcare system. In the case of unstable borderline personality disorder, that will actually serve her better since they have more resources. But I can see the transference and splitting starting already because she'll definitely not like the 15 minute med checks and long waits for a follow up visit as well as the waits to get a call back from the MD. Most likely it will be from the RN. I did have a similar case to this in residency. In 5 months her new doc was the worst person in the world and she begged me to take her back. I told her it would actually be more therapeutic to work with that doc and the interpersonal conflict as it is a hallmark of her primary disorder...the irony.

 

[Salpingo]

I have a patient, who I've gotten to know for nearly five months. Overtime, there was an enduring pattern of chronic interpersonal chaos, passive SI, emotional lability, and impulsivity. Not surprisingly, little response to medications. I initially started her on a low dose antidepressant. Early on, I suspected at the very least she'd benefit from DBT but she failed to follow-up on this and I did start her on some antipsychotic augmentation. At least it can serve both as a mood stabilizer and augment antidepressants if there's a differential of MDD, bipolar, or borderline. Not to say that people with borderline personality disorder cannot have bipolar disorder or other comorbidities. But, the chronicity and unrelenting course of her symptoms suggested her primary diagnosis was most likely borderline personality disorder. I broke the diagnosis to her, as I continued to emphasize DBT over this being a medication issue, she got upset and checked herself inpatient. I encouraged the inpatient doc to call me so I can help coordinate care. He didn't and slaps her with a "bipolar" diagnosis which she was much happier about (I feel like a lot of patients prefer this since they feel it puts more onus on the medication to do the work for them than pursuing something like DBT). Fortunately, the patient is not mad at me, but there is some idealization of this inpatient psychiatrist who told her she has bipolar after seeing her just once and not even consulting with me. She likes him so much she wants to follow up with him outpatient. It's actually a relief for me, and we'll see how accurate he thinks his diagnosis is after the ten thousandth call she's given him. She used to call me relentlessly.

But really, I just don't get it. Outpatient psychiatrist calls to help give information and yet the inpatient doc draws his own conclusion of bipolar disorder? I'm thinking wtf a little....my only beef with this is that it feels like one step back for the patient. Instead of pursuing DBT there is more enabling and less potential for real progress to be made. Oh well, won't be my case anymore but I admit I really don't like seeing delays in potential progress.

At least now you can add splitting to the list of symptoms confirming your diagnosis.

It sucks, especially after 5 months of work. I'd recommend picking up one of John Gunderson's handbooks/manuals. He makes a point of meeting the patient where they are in terms of diagnosis, and that psychotherapy can only really work if the person feels there's some sort of behavior on their part that's making their life so miserable. You can do your best to provide the appropriate psychoeducation, but after awhile its about creating a safe "holding" environment to keep the patient from going bad to worse.

But get ready when the patient comes back with clonazepam 2mg TID (with alprazolam for breakthrough), lamotrigine 400mg daily, quetiapine 50mg qam, 200mg qhs, Topimax 100mg (cuz migraines, definitely not because it says it causes weight loss online), brexipiprazole 2mg, prazosin 10mg qhs, modafinil 200mg (because that's not medication-induced sedation, its a neurovegetative symptom of their bipolar depression). Assuming they don't have chronic pain/fibromyalgia...

 

[randomdoc1]

At least now you can add splitting to the list of symptoms confirming your diagnosis.

It sucks, especially after 5 months of work. I'd recommend picking up one of John Gunderson's handbooks/manuals. He makes a point of meeting the patient where they are in terms of diagnosis, and that psychotherapy can only really work if the person feels there's some sort of behavior on their part that's making their life so miserable. You can do your best to provide the appropriate psychoeducation, but after awhile its about creating a safe "holding" environment to keep the patient from going bad to worse.

But get ready when the patient comes back with clonazepam 2mg TID (with alprazolam for breakthrough), lamotrigine 400mg daily, quetiapine 50mg qam, 200mg qhs, Topimax 100mg (cuz migraines, definitely not because it says it causes weight loss online), brexipiprazole 2mg, prazosin 10mg qhs, modafinil 200mg (because that's not medication-induced sedation, its a neurovegetative symptom of their bipolar depression). Assuming they don't have chronic pain/fibromyalgia...

haha! Oh she somatizes plenty. Is that the experience of other people here who've managed pts with borderline personality disorder? She's seen many specialists for her GI complaints. It reminds me of another pt I saw on the inpatient unit, primary disorder: borderline personality. She was so impressively morbidly obese from all the antipsychotics she was on. I mean, wheelchair bound. She still didn't get the picture and kept insisting it was a med issue. I really feel bad for some of these cases but I understand at some point we just have to let it go and say we gave it our best. I'll look into other ways of reframing the diagnosis. In most cases, I've had success with telling people when they primarily have borderline personality disorder. But the remaining 20% can be a real kicker. Especially when it seems the answer and appropriate treatment are well within reach and it is flat out refused and you know of the polypharmacy nightmare that could await...

Oh, and BTW, you forgot the Adderall XR 30mg qam and 30mg IR for break through for the newly found ADHD that was missed by everyone else during their lifetime. xD

 

[Ceke2002]

Sounds like she's in training for the Mental Illness Olympics. Why settle for a measly 4th or 5th place diagnosis like BPD, when you could potentially score yourself a gold medal in Bipolar Disorder.

 

[clausewitz2]

This won't really help now, but in my experience about 80% of the time if I give a patient with BPD an article explaining what it is, they immediately identify all of their symptoms and recognize it within themselves. The other 20% seem to be people with some mix of narcissistic PD, or actual BPD but aware enough they don't want the pejorative label.

I will never forget asking one of my inpatients "has anyone ever mentioned something like borderline personality disorder to you?" , performing basic psychoeducation, and passing them on the phone later that afternoon to hear them saying, "mom, there's this thing, borderline personality, and it explains so much..."

I feel like anyone presenting who has had rather a lot of contact with the system but states that they "want to know what's really wrong" is a bit of a soft sign.

 

[Crayola227]

what strikes me as particularly frustrating, is the other psychiatrist playing into this

like, they should really know better

the patient is just playing out their typical pathology, and all of us docs should be pretty inured to that, but for me at least, it's more frustrating when other providers make mistakes they really should know better not to make

any inpt psychiatrist should know better than to toss out an ongoing psych's dx of BPD for BPAD based on one inpt visit without signs of florid mania

 

[TexasPhysician]

While I agree that the inpatient doc should always consult with the outpatient doc, you shouldn't expect the inpatient doc to follow your diagnosis.

I highly doubt most insurance companies reimburse inpatient stays for a borderline exacerbation, but I could be wrong. This is similar to ADHD kids always getting a mood disorder at inpatient. Insurance companies won't pay because the ADHD kid impulsively kicked his mother, but if the "bipolar" mother kicked his mother in an "aggressive rage" then you get reimbursed.

The system is not designed for the care of patients.


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[randomdoc1]

what strikes me as particularly frustrating, is the other psychiatrist playing into this

like, they should really know better

the patient is just playing out their typical pathology, and all of us docs should be pretty inured to that, but for me at least, it's more frustrating when other providers make mistakes they really should know better not to make

any inpt psychiatrist should know better than to toss out an ongoing psych's dx of BPD for BPAD based on one inpt visit without signs of florid mania

That too! I left a message on the inpatient unit after the pt signed a release that I would be available for the inpatient attending to call me. I consider consulting with the outpatient doc who's had multiple encounters with the pt over the course of months to be standard of care (especially if you're going to slap on a BPAD diagnosis after one visit when BPD is in the ddx...somehow an image of giving a BPD patient ECT after a rashly made ddx of mania is made is popping into my head and that unfortunately happens too). When I work inpatient, I just about always do this as there is often more to the history than what the patient says. In this patient in particular, she will endorse anything. On my intake, she endorsed almost all the criteria for OCD, GAD, panic disorder, MDD, and PTSD. That was what made me suspicious of Axis II involvement at the very least.

While I agree that the inpatient doc should always consult with the outpatient doc, you shouldn't expect the inpatient doc to follow your diagnosis.

I highly doubt most insurance companies reimburse inpatient stays for a borderline exacerbation

Which is unfortunate 🙁. I've seen this on the inpatient units too and feel it just feeds into the invalidation some patients experience. Yes, ideally if the primary issue is a personality disorder and the symptoms are chronic, you don't want to hospitalize the patient in many cases as it can worsen their course. However, people with borderline personality disorder do experience exacerbations and do have an elevated suicide risk which I wish insurance companies wouldn't be so black and white about.

 

[michaelrack]

I am an inpatient psych...don't typically consult with outpatient doc...the poor patients r seen for a few minutes every 3 months at the county psych clinic and the rich are on at least 2 of the following: stim, benzo, suboxone

 

[thoffen]

Sure the inpatient doc didn't do the right thing in at least consulting with you, but I think the whole shebang was rather predictable anyway. First, although DBT is the test answer as panacea for BPD, it is far from the only effective psychotherapy and also not the right treatment for many (bad fit, cost, lack of investment in treatment). But it seems more important that you have an explicit discussion with your patient about the boundaries of your treatment, your proposed treatment plan, plan for handling crises, and consequences of going outside the boundaries. Making a clear plan and sticking with it is how you can enforce treatment boundaries without being rejecting.

 

[thoffen]

I highly doubt most insurance companies reimburse inpatient stays for a borderline exacerbation, but I could be wrong. This is similar to ADHD kids always getting a mood disorder at inpatient. Insurance companies won't pay because the ADHD kid impulsively kicked his mother, but if the "bipolar" mother kicked his mother in an "aggressive rage" then you get reimbursed.

The system is not designed for the care of patients.

I agree, but it's also true that many inpatient docs don't really understand what they can get reimbursement for and how to document their findings to help in this way.

Firstly, it does seem that the patient is having outpatient treatment for a mood disorder. This is commonly comorbid with BPD, so using that as the principle diagnosis solves all our problems in this case. But there are the borderline patients who are presenting for pure borderline crisis and aren't thought to have an underlying mood episode causing the problem. In this case, the first question is whether it is appropriate to admit them at all (regardless of stated safety concern) and if so clearly defining the goals of the hospitalization and criteria for discharge up front. Hopefully, a patient is engaged in psychotherapy and/or psychiatry already and ideally has a plan for these crises already established to follow, but most often not, and it's prudent at that time to engage outpatient team in planning ahead for the next crisis. But you can at least contact outpatient providers and see if they are willing to care for patient as OP even if elevated risk if there doesn't seem to be an inpatient intervention that will mitigate that risk.

Otherwise, you are left with a patient you are either unsure if they have a mood (or other) disorder to treat but need to accomplish something in the hospital (diagnostic clarity, proper outpatient treatment bridge, resolution of perceived abandonment, etc.) before they can go. In these cases, you can use a rule-out diagnosis as the principle diagnosis. You can even document you think they don't have it. But if they are unsafe and you are doing something diagnostically to clarify it and get them to outpatient ASAP when appropriate, you'll be A-OK. Doing and documenting things like gathering collateral from family and providers, collaborating on outpatient plan, finding residential/IOP/PHP program, etc. all help you with insurance companies because they know you are not letting them sit around without an active plan or treatment.

My biggest problem is being handcuffed into starting pharmacotherapy when I think it's not indicated. Thankfully the majority are already on meds, so you can do something with that.

Also, your d/c documentation does not have to reflect the initial diagnosis. You can admit for R/O MDD and d/c as BPD. I don't know if that might cause problems for reimbursement on day of d/c, but that is time-based billing anyway.

 

[COXblocker]

Ah the ol' "triangle of misdiagnosis". Psychosis, Depression, and Mania at the points, and schizoaffective and BP connecting. All surrounding the real issue, the great imitator, borderline personality.

Separately, this lecture was recommended by a colleague. I have plenty of disagreements, but this is a common belief system about bipolar

 

[Shikima]

Ah the ol' "triangle of misdiagnosis". Psychosis, Depression, and Mania at the points, and schizoaffective and BP connecting. All surrounding the real issue, the great imitator, borderline personality.

Separately, this lecture was recommended by a colleague. I have plenty of disagreements, but this is a common belief system about bipolar

This needs to be a CME activity.

 

[Ceke2002]

Sure the inpatient doc didn't do the right thing in at least consulting with you, but I think the whole shebang was rather predictable anyway. First, although DBT is the test answer as panacea for BPD, it is far from the only effective psychotherapy and also not the right treatment for many (bad fit, cost, lack of investment in treatment). But it seems more important that you have an explicit discussion with your patient about the boundaries of your treatment, your proposed treatment plan, plan for handling crises, and consequences of going outside the boundaries. Making a clear plan and sticking with it is how you can enforce treatment boundaries without being rejecting.

I know quite a few people with a diagnosis of BPD who have dropped out of DBT in favour of other therapies, after finding DBT to not only not be effective for them, but almost cultish in its application. It's also an unfortunate truth that once you have a diagnosis of BPD, there are some providers out there who will automatically dismiss any and all co-morbid diagnoses as simply being part of the overall pattern of instability and presumed manipulation. In these cases I can understand someone wanting a different diagnosis that they feel might actually be taken more seriously, and not treated in such a dismissive manner.

 

[Crayola227]

it might be unreasonable to expect the inpt doc to reach out to every outpt psychiatrist about every patient,

but when the outpt doc makes a point of reaching out to you about a patient,

I think it's professional courtesy to return the communication in some way beyond the d/c summary

this whole thing sits very poorly with me is all

 

[clausewitz2]

it might be unreasonable to expect the inpt doc to reach out to every outpt psychiatrist about every patient,

but when the outpt doc makes a point of reaching out to you about a patient,

I think it's professional courtesy to return the communication in some way beyond the d/c summary

this whole thing sits very poorly with me is all

Our shop is currently on a massive QI tear that involves, among other things, a campaign to make sure we document at least one attempt to speak to an outpatient psychiatrist at least once during every single inpatient admission. We are up in the 60s right now percent-wise.

 

[okokok]

While I agree that the inpatient doc should always consult with the outpatient doc, you shouldn't expect the inpatient doc to follow your diagnosis.

I highly doubt most insurance companies reimburse inpatient stays for a borderline exacerbation, but I could be wrong. This is similar to ADHD kids always getting a mood disorder at inpatient. Insurance companies won't pay because the ADHD kid impulsively kicked his mother, but if the "bipolar" mother kicked his mother in an "aggressive rage" then you get reimbursed.

The system is not designed for the care of patients.


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Ohhh this explains so much about my current inpatient rotation (M4)

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[randomdoc1]

but when the outpt doc makes a point of reaching out to you about a patient,

I think it's professional courtesy to return the communication

This! I rarely have outpatient docs try to reach me when I am working inpatient. If anything, I have a hard time trying to reach the outpatient docs. I agree it may be unrealistic to try to reach every outpatient provider. But when an outpatient provider tries to reach me...so far they've always had something helpful to offer and it is often a red flag to me that something else is up with the patient than first meets the eye.

 

[LasVagus]

While I agree that the inpatient doc should always consult with the outpatient doc, you shouldn't expect the inpatient doc to follow your diagnosis.

I highly doubt most insurance companies reimburse inpatient stays for a borderline exacerbation, but I could be wrong. This is similar to ADHD kids always getting a mood disorder at inpatient. Insurance companies won't pay because the ADHD kid impulsively kicked his mother, but if the "bipolar" mother kicked his mother in an "aggressive rage" then you get reimbursed.

The system is not designed for the care of patients.


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Exactly! I actually think this is one of the biggest problems in all of psychiatry right now! I see diagnoses being routinely changed to get people into certain programs or to justify certain hospitalizations. In my state, traumatic brain injury cannot be a reason for involuntary psychiatric hospitalization. So someone with severe damage to the frontal lobe who frequently becomes violent and tried to strangle his mother? Bipolar. I mean, after all, he is exhibiting irritability, right? Such nonsense.

 

[nexus73]

Ah the ol' "triangle of misdiagnosis". Psychosis, Depression, and Mania at the points, and schizoaffective and BP connecting. All surrounding the real issue, the great imitator, borderline personality.

Separately, this lecture was recommended by a colleague. I have plenty of disagreements, but this is a common belief system about bipolar

Can you summarize the high yield point(s) of the video?

 

[WingedOx]

Our shop is currently on a massive QI tear that involves, among other things, a campaign to make sure we document at least one attempt to speak to an outpatient psychiatrist at least once during every single inpatient admission. We are up in the 60s right now percent-wise.

ours too... though it's a closed shop here at the VA so there's not really an excuse not to. Even an instant message is more than sufficient most of the time.

 

[WingedOx]

Exactly! I actually think this is one of the biggest problems in all of psychiatry right now! I see diagnoses being routinely changed to get people into certain programs or to justify certain hospitalizations. In my state, traumatic brain injury cannot be a reason for involuntary psychiatric hospitalization. So someone with severe damage to the frontal lobe who frequently becomes violent and tried to strangle his mother? Bipolar. I mean, after all, he is exhibiting irritability, right? Such nonsense.

No luck with some variant of impulse control disorder?

Ironically I'm having a tangentially related problem this month with patients asking me to add a PTSD diagnosis into their chart because of their belief that it will get them out of legal trouble for whatever bar fight they got into this summer.

 

[splik]

I highly doubt most insurance companies reimburse inpatient stays for a borderline exacerbation, but I could be wrong. This is similar to ADHD kids always getting a mood disorder at inpatient. Insurance companies won't pay because the ADHD kid impulsively kicked his mother, but if the "bipolar" mother kicked his mother in an "aggressive rage" then you get reimbursed.

The system is not designed for the care of patients.

There is technically, no such a thing as a "borderline exacerbation" (though we know what it means) which is why insurances won't pay for it. They will however pay for suicidal ideation (R45.851 or suicide attempt T14.91, or intentional self harm) or violent/homicidal ideation or behavior that is the direct result of a mental disorder (including BPD). most of the time, admission is not appropriate for borderline patients anyway unless they meet the other criteria. There is absolutely no reason to diagnose someone with bipolar disorder when they don't have it, and in fact to do so knowing the pt does not have it is fraud. It is a myth that you have to lie to get these patients in, and all it does is makes it more difficult when people try to be honest because then it looks like no one is admitting borderline pts. I admit patients with borderline diagnoses all the time (along with the R45.851 as the reason for admission), and have even treated inpatients with adjustment disorders or bereavement reaction (though they definitely don't have to cover it). As long as the patient actually would benefit from hospitalization and meets criteria they are covered. At any rate, it is one thing to fudge paperwork for reimbursement (fraud) and another to tell the patient they have a dx they don't have and inappropriately treat them leading to iatrogenic harm (malpractice).

As for ADHD - well I'm not a child psychiatrist, but I would question the value of admitting a child on the basis of a diagnosis of ADHD anyway - how would hospitalization be helpful? If there are additional circumstances that warrant admission then "severe emotional disturbance of a child" is considered a parity diagnosis and thus they have to cover treatment (including inpt) for behavioral disturbances in children that pose a risk to them or others and/or may lead to their removal from the home. If you want a bs diagnosis one of the disruptive ones (e.g. DMDD) would be more appropriate than bipolar.

Diagnoses have real consequences for people. They have implications for future life insurance, for what jobs people might get, for health insurance coverage (if obamacare disappears), for what treatment patients get, stigma, for how they come to see themselves or develop a sense of identity. It is potentially quite harmful to diagnose patients with bipolar disorder when they don't have it. especially if they end up on neuroleptics and other toxic drugs they don't need.

 

[TexasPhysician]

There is technically, no such a thing as a "borderline exacerbation" (though we know what it means) which is why insurances won't pay for it. They will however pay for suicidal ideation (R45.851 or suicide attempt T14.91, or intentional self harm) or violent/homicidal ideation or behavior that is the direct result of a mental disorder (including BPD). most of the time, admission is not appropriate for borderline patients anyway unless they meet the other criteria. There is absolutely no reason to diagnose someone with bipolar disorder when they don't have it, and in fact to do so knowing the pt does not have it is fraud. It is a myth that you have to lie to get these patients in, and all it does is makes it more difficult when people try to be honest because then it looks like no one is admitting borderline pts. I admit patients with borderline diagnoses all the time (along with the R45.851 as the reason for admission), and have even treated inpatients with adjustment disorders or bereavement reaction (though they definitely don't have to cover it). As long as the patient actually would benefit from hospitalization and meets criteria they are covered. At any rate, it is one thing to fudge paperwork for reimbursement (fraud) and another to tell the patient they have a dx they don't have and inappropriately treat them leading to iatrogenic harm (malpractice).

As for ADHD - well I'm not a child psychiatrist, but I would question the value of admitting a child on the basis of a diagnosis of ADHD anyway - how would hospitalization be helpful? If there are additional circumstances that warrant admission then "severe emotional disturbance of a child" is considered a parity diagnosis and thus they have to cover treatment (including inpt) for behavioral disturbances in children that pose a risk to them or others and/or may lead to their removal from the home. If you want a bs diagnosis one of the disruptive ones (e.g. DMDD) would be more appropriate than bipolar.

Diagnoses have real consequences for people. They have implications for future life insurance, for what jobs people might get, for health insurance coverage (if obamacare disappears), for what treatment patients get, stigma, for how they come to see themselves or develop a sense of identity. It is potentially quite harmful to diagnose patients with bipolar disorder when they don't have it. especially if they end up on neuroleptics and other toxic drugs they don't need.

Can you educate the local inpatient psychiatrists about this? I undiagnose bipolar 50x more than I diagnose it.


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[Shikima]

Can you educate the local inpatient psychiatrists about this? I undiagnose bipolar 50x more than I diagnose it.


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"It's my bipolar acting up."

 

[thoffen]

"It's my bipolar acting up."

Yeah but that's not as bad as my bipolar schizophrenia!

 

[okokok]

There is technically, no such a thing...

Diagnoses have real consequences for people. They have implications for future life insurance, for what jobs people might get, for health insurance coverage (if obamacare disappears), for what treatment patients get, stigma, for how they come to see themselves or develop a sense of identity. It is potentially quite harmful to diagnose patients with bipolar disorder when they don't have it. especially if they end up on neuroleptics and other toxic drugs they don't need.

1. This post taught me some important things, thank you
2. I strongly agree with your last paragraph and I appreciate your mentioning it
3. Out of curiosity, do insurers reimburse at different rates for these things? Eg, is a bipolar episode reimbursed at a higher rate than suicidal ideation?

 

[Shikima]

Same reimbursement rate for all Dx. Documentation provided determines billing level.

Btw, use F39 for mood disorder NOS. I would respect the psychiatrist more who did this and it's still a billable code.

 

[st2205]

Same reimbursement rate for all Dx. Documentation provided determines billing level.

Btw, use F39 for mood disorder NOS. I would respect the psychiatrist more who did this and it's still a billable code.

That my favorite diagnosis. It also lets everyone know what's up. At least it should.

 

[splik]

Can you educate the local inpatient psychiatrists about this? I undiagnose bipolar 50x more than I diagnose it.

I think you are being charitable, thinking they just do it for reimbursement. I'm sure that factors in but from what I've seen, a lot of psychiatrists really do believe it's all bipolar, or figure it could be, or that they can treat bipolar but can't treat borderline so they'll just call it bipolar and see what happens. I was moonlighting a few months ago and saw an inpt who got a mixed bipolar dx. He had a panic attack. I **** you not. a panic attack. I described in detail why he did not have bipolar and the correct dx, and took him off depakote and seroquel only to find that the psychiatrist a few days later rediagnosed the patient with bipolar and restarted those meds... this kind of crap happens all the time.

1. This post taught me some important things, thank you
2. I strongly agree with your last paragraph and I appreciate your mentioning it
3. Out of curiosity, do insurers reimburse at different rates for these things? Eg, is a bipolar episode reimbursed at a higher rate than suicidal ideation?

it sounds like you've been having a terrible inpt rotation. unfortunately a lot of what you describe passes for psychiatry in many places so be sure to try and sniff this out when interviewing for residency. Reimbursement is based on time OR it is based on complexity, not on diagnosis. btw you would put bipolar AND you would put suicidal ideations or suicidal ideations AND borderline (not just SI). actually, coding for SI can help in showing complexity or severity of the case and thus help maximize billing, but many psychiatrists fail to code for it because they don't understand how to use ICD-10. There are lots of myths about billing. For instance that you need a DSM diagnosis. Since most insurances (including medicaid and medicare) do not recognize DSM diagnoses for billing this is untrue. Also on the C/L service for example, we see patients who don't have a psych diagnosis all the time, and yes you do get reimbursed for the encounters. In outpatient C/L the visit might be a pre-transplant or bariatric surgery eval. you put that as the "diagnosis" when coding. What is true, is there are certain diagnoses that are "parity diagnoses" meaning that insurances HAVE to cover care for them in the same way as for other medical conditions. adjustment disorders, personality disorders, substance use disorders aren't parity diagnoses (though substance induced mood, anxiety, and psychotic disorders are) which means that insurances don't have to cover unlimited psychotherapy or pay for inpt admissions for them. but we don't admit patients because they're borderline (at least we shouldn't)- we admit patients because of dangerousness to self or others or grave disability, and insurances do cover this. Another point is that if you have a schizophrenia or bipolar dx then insurances tend to authorize longer stays for inpt. For BPD or substance-induced states they will usually authorize like 2 days at a time so you have to keep calling back to get approval for more days. Psychiatrists get annoyed about it, but it is because there was so many BS admissions that insurances have clamped down on this sort of thing and want justification. It is a nuisance, but it is largely one of our own creation.

 

[WingedOx]

Same reimbursement rate for all Dx. Documentation provided determines billing level.

Btw, use F39 for mood disorder NOS. I would respect the psychiatrist more who did this and it's still a billable code.

One of my peeves about using CPRS as opposed to my old Cerner chart is that it doesn't prominently display ICD10 codes when you bill. I swear I still know far more ICD9s than 10s from memory despite the fact we've been using 10 for longer than I ever used 9 in the outpatient setting.

I need to make flash cards or something.

 

[deleted736562]

I'm wondering what people think about those patients who have total extremes in mood, can be even chronically delusional, but have decent insight into their perceptual disturbances (i.e tend to be aware that these are not completely real), and it all seems to stem from a personality disturbance. For example, a chronically delusional patient that her life is a movie being watched by everyone else (pt in that case tended to be really sensitive to criticism). I think these sort of patient tend to escape the borderline diagnosis just because of the intensity of the psychosis/mood lability and be branded bipolar/schizoaffective, but otherwise have all the features of borderline. It's perhaps an extreme of borderline personality disorder that is not being recognized? I know that there used to be a diagnosis of pseudoneurotic schizophrenia in the past which ended up morphing into borderline personality disorder.

 

[Shikima]

I think you are being charitable, thinking they just do it for reimbursement. I'm sure that factors in but from what I've seen, a lot of psychiatrists really do believe it's all bipolar, or figure it could be, or that they can treat bipolar but can't treat borderline so they'll just call it bipolar and see what happens. I was moonlighting a few months ago and saw an inpt who got a mixed bipolar dx. He had a panic attack. I **** you not. a panic attack. I described in detail why he did not have bipolar and the correct dx, and took him off depakote and seroquel only to find that the psychiatrist a few days later rediagnosed the patient with bipolar and restarted those meds... this kind of crap happens all the time.


it sounds like you've been having a terrible inpt rotation. unfortunately a lot of what you describe passes for psychiatry in many places so be sure to try and sniff this out when interviewing for residency. Reimbursement is based on time OR it is based on complexity, not on diagnosis. btw you would put bipolar AND you would put suicidal ideations or suicidal ideations AND borderline (not just SI). actually, coding for SI can help in showing complexity or severity of the case and thus help maximize billing, but many psychiatrists fail to code for it because they don't understand how to use ICD-10. There are lots of myths about billing. For instance that you need a DSM diagnosis. Since most insurances (including medicaid and medicare) do not recognize DSM diagnoses for billing this is untrue. Also on the C/L service for example, we see patients who don't have a psych diagnosis all the time, and yes you do get reimbursed for the encounters. In outpatient C/L the visit might be a pre-transplant or bariatric surgery eval. you put that as the "diagnosis" when coding. What is true, is there are certain diagnoses that are "parity diagnoses" meaning that insurances HAVE to cover care for them in the same way as for other medical conditions. adjustment disorders, personality disorders, substance use disorders aren't parity diagnoses (though substance induced mood, anxiety, and psychotic disorders are) which means that insurances don't have to cover unlimited psychotherapy or pay for inpt admissions for them. but we don't admit patients because they're borderline (at least we shouldn't)- we admit patients because of dangerousness to self or others or grave disability, and insurances do cover this. Another point is that if you have a schizophrenia or bipolar dx then insurances tend to authorize longer stays for inpt. For BPD or substance-induced states they will usually authorize like 2 days at a time so you have to keep calling back to get approval for more days. Psychiatrists get annoyed about it, but it is because there was so many BS admissions that insurances have clamped down on this sort of thing and want justification. It is a nuisance, but it is largely one of our own creation.

Funny. I just got a new patient with a long history of anxiety and panic attacks who was diagnosed with Bipolar Disorder and had been treated with Lamictal only. Surprise, it wasn't working.

 

[Shikima]

I'm wondering what people think about those patients who have total extremes in mood, can be even chronically delusional, but have decent insight into their perceptual disturbances (i.e tend to be aware that these are not completely real), and it all seems to stem from a personality disturbance. For example, a chronically delusional patient that her life is a movie being watched by everyone else (pt in that case tended to be really sensitive to criticism). I think these sort of patient tend to escape the borderline diagnosis just because of the intensity of the psychosis/mood lability and be branded bipolar/schizoaffective, but otherwise have all the features of borderline. It's perhaps an extreme of borderline personality disorder that is not being recognized? I know that there used to be a diagnosis of pseudoneurotic schizophrenia in the past which ended up morphing into borderline personality disorder.

One of my borderlines yesterday was describing alterations in perception where the sky was getting bigger.

 

[randomdoc1]

Excellent input everyone! Especially that you actually CAN put in the correct dx in the inpatient setting and just put something like SI/SA to help with the reimbursement piece. Yes, I've seen other things mislabeled as bipolar too. Includes PTSD, GAD, and even panic attacks once! Often times sometimes just plain old unipolar depression or guess what...delirium! But it's spot on that misdiagnosing opens up the way for a very scary path for patients: iatrogenic complications, not using SSRI/SNRI when it is clearly indicated, missed medical problems, etc. For people who saw my other posts, I once saw DTs missed in the outpatient setting and it was mistaken for bipolar. But the path that patients with borderline personality disorder can go down is scary. I've lost track of the number of scary polypharmacy cases I've come across, including one case of NMS.

 

[WingedOx]

One of my borderlines yesterday was describing alterations in perception where the sky was getting bigger.

 

[Shikima]

Excellent input everyone! Especially that you actually CAN put in the correct dx in the inpatient setting and just put something like SI/SA to help with the reimbursement piece. Yes, I've seen other things mislabeled as bipolar too. Includes PTSD, GAD, and even panic attacks once! Often times sometimes just plain old unipolar depression or guess what...delirium! But it's spot on that misdiagnosing opens up the way for a very scary path for patients: iatrogenic complications, not using SSRI/SNRI when it is clearly indicated, missed medical problems, etc. For people who saw my other posts, I once saw DTs missed in the outpatient setting and it was mistaken for bipolar. But the path that patients with borderline personality disorder can go down is scary. I've lost track of the number of scary polypharmacy cases I've come across, including one case of NMS.

If you can't diagnose correctly, how do you know what the appropriate treatment is?

 

[randomdoc1]

I described in detail why he did not have bipolar and the correct dx, and took him off depakote and seroquel only to find that the psychiatrist a few days later rediagnosed the patient with bipolar and restarted those meds... this kind of crap happens all the time.

Yikes, I see metabolic syndrome and OSA down the road for that guy...maybe some alopecia too. Since we're not treating the underlying disorder, more frequent follow-ups and/or hospitalizations. But hey...we can add OSA and metabolic syndrome so it can increase the complexity level and we get paid better right? 😀

 

[Shikima]

Yikes, I see metabolic syndrome and OSA down the road for that guy...maybe some alopecia too. Since we're not treating the underlying disorder, more frequent follow-ups and/or hospitalizations. But hey...we can add OSA and metabolic syndrome so it can increase the complexity level and we get paid better right? 😀

yes you can. It's part of E&M coding principles.

 

[st2205]

As a side note, when do people add on non-psychiatric stuff for billing (outpatient), and what are you doing to 'address' it? Recommend CPAP compliance for OSA? Recommend talk to PCP for elevated BP? Tagging hyperlipidemia on encounters where you order lipid panel on people with the diagnosis already?

 

[Shikima]

As a side note, when do people add on non-psychiatric stuff for billing (outpatient), and what are you doing to 'address' it? Recommend CPAP compliance for OSA? Recommend talk to PCP for elevated BP? Tagging hyperlipidemia on encounters where you order lipid panel on people with the diagnosis already?

You don't have to apply treatment to make a difference. You've recognized it and create a treatment plan with the appropriate service line to fix it.

 

[Ceke2002]

I'm wondering what people think about those patients who have total extremes in mood, can be even chronically delusional, but have decent insight into their perceptual disturbances (i.e tend to be aware that these are not completely real), and it all seems to stem from a personality disturbance. For example, a chronically delusional patient that her life is a movie being watched by everyone else (pt in that case tended to be really sensitive to criticism). I think these sort of patient tend to escape the borderline diagnosis just because of the intensity of the psychosis/mood lability and be branded bipolar/schizoaffective, but otherwise have all the features of borderline. It's perhaps an extreme of borderline personality disorder that is not being recognized? I know that there used to be a diagnosis of pseudoneurotic schizophrenia in the past which ended up morphing into borderline personality disorder.

Warning: Personal experience ahoy.

I actually have a dual diagnosis (I think that's the correct term) of residual BPD, or whatever the correct term for when someone has previously been diagnosed with BPD but no longer meets full diagnostic criteria is (PD-NOS, perhaps?), and occasional MDD with Psychotic Fx. I've personally found the trick for me is being able to figure out/recognise when certain disturbances in thought and perception is a result of things like emotional dysregulation, unstable sense of self and/or hypervigilant states associated with previous trauma issues, and when those things are a result of something else. And naturally my Psychiatrist also needs to be able to ascertain when therapy alone is suitable to bring certain symptoms back under control, and when he needs to pull out the prescription pad instead. All I can say is that, for me at least, there is a distinct difference in the quality of thought and perceptual disturbances associated with personality disorder/prior trauma issues, and those associated with MDD with Psychotic Fx (even with intact insight). The experiences can seem the same, but they sort of 'feel' different, like almost on a biological level kind of a difference. It's one of those things that's really hard to explain properly though.

 

[Salpingo]

I think you are being charitable, thinking they just do it for reimbursement. I'm sure that factors in but from what I've seen, a lot of psychiatrists really do believe it's all bipolar, or figure it could be, or that they can treat bipolar but can't treat borderline so they'll just call it bipolar and see what happens. I was moonlighting a few months ago and saw an inpt who got a mixed bipolar dx. He had a panic attack. I **** you not. a panic attack. I described in detail why he did not have bipolar and the correct dx, and took him off depakote and seroquel only to find that the psychiatrist a few days later rediagnosed the patient with bipolar and restarted those meds... this kind of crap happens all the time.


it sounds like you've been having a terrible inpt rotation. unfortunately a lot of what you describe passes for psychiatry in many places so be sure to try and sniff this out when interviewing for residency. Reimbursement is based on time OR it is based on complexity, not on diagnosis. btw you would put bipolar AND you would put suicidal ideations or suicidal ideations AND borderline (not just SI). actually, coding for SI can help in showing complexity or severity of the case and thus help maximize billing, but many psychiatrists fail to code for it because they don't understand how to use ICD-10. There are lots of myths about billing. For instance that you need a DSM diagnosis. Since most insurances (including medicaid and medicare) do not recognize DSM diagnoses for billing this is untrue. Also on the C/L service for example, we see patients who don't have a psych diagnosis all the time, and yes you do get reimbursed for the encounters. In outpatient C/L the visit might be a pre-transplant or bariatric surgery eval. you put that as the "diagnosis" when coding. What is true, is there are certain diagnoses that are "parity diagnoses" meaning that insurances HAVE to cover care for them in the same way as for other medical conditions. adjustment disorders, personality disorders, substance use disorders aren't parity diagnoses (though substance induced mood, anxiety, and psychotic disorders are) which means that insurances don't have to cover unlimited psychotherapy or pay for inpt admissions for them. but we don't admit patients because they're borderline (at least we shouldn't)- we admit patients because of dangerousness to self or others or grave disability, and insurances do cover this. Another point is that if you have a schizophrenia or bipolar dx then insurances tend to authorize longer stays for inpt. For BPD or substance-induced states they will usually authorize like 2 days at a time so you have to keep calling back to get approval for more days. Psychiatrists get annoyed about it, but it is because there was so many BS admissions that insurances have clamped down on this sort of thing and want justification. It is a nuisance, but it is largely one of our own creation.

It's been awhile since I've worked inpatient (primarily because I hate this crap), but the lore that was passed down was that it's harder to get prior authorization for the BPD diagnosis (or any PD diagnosis for that matter, given the number of sociopaths and narcissists we saw). That may be different with parity laws under AHA (or in California), but as a result, there was an epidemic of mood disorder NOS (not particularly helpful, maybe a little negligent, but fallsing short of malpractice or fraud).

I'd imagine the insurance logic for denying days to someone diagnosed with SI or even attempt is that BPD patients will have chronic SI. We almost had a patient rejected because they were a health professional, and they would know that their SA would not be significantly lethal to kill them (ignoring the events and affect leading up to their attempt).

Ultimately, the rationale for admitting a patient for BPD is to repair or put in place outpatient resources while the patient reconstitutes themselves, maybe diagnostic clarification if there are medical, substance or micro-psychotic elements to the presentation. It'd be great if the insurance just put the $10,000, or whatever the cost of admissions, to an outpatient service (all of a sudden, they would be our favorite patient). Of course, it would be a little too easy to game that system...