ICD 10 Coding Alert

Hint: Report other associated sleep conditions with additional ICD-10 codes.

When your clinician diagnoses sleep apnea, you can breathe easy as the ICD-10 coding system is more simplified than the ICD-9 codes. You now have to report only one specific code for sleep apnea while you have multiple choices in ICD-9. In ICD-9, you have to report other code choices when this condition occurs with other sleep related conditions such as insomnia or hypersomnia.

ICD-9: When your clinician diagnoses sleep apnea but does not specify the cause for the apnea, you will choose 780.57 (Unspecified sleep apnea). When your physician documents sleep apnea with either insomnia or hyposomnia, report it with the ICD-9 code 780.51 (Insomnia with sleep apnea, unspecified). If however, your physician documents sleep apnea with hypersomnia, you report ICD-9 code 780.53 (Hypersomnia with sleep apnea, unspecified).

Caveat: You cannot use the 780.5x series of ICD-9 codes if your clinician identifies the condition as circadian rhythm sleep disorders (327.30-327.39); organic hypersomnia (327.10-327.19); organic insomnia (327.00-327.09); organic sleep apnea (327.20-327.29); organic sleep related movement disorders (327.51-327.59); parasomnias (327.40-327.49), or of nonorganic  origin (307.40-307.49). If your clinician identifies the condition as obstructive sleep apnea, then you will have to report it with 327.23 (Obstructive sleep apnea [adult] [pediatric]).

ICD-10: In ICD-10, you will have to use G47- (Sleep disorders) when reporting any sleep disorders. But unlike in ICD-9, you do not have different ICD-10 codes when your clinician is identifying apnea with insomnia, hyposomnia or hypersomnia. When your clinician identifies apnea but does not identify the cause for the apnea, you will have to report the condition with G47.30 (Sleep apnea, unspecified). If your clinician also identifies other sleep disturbances such as insomnia or hypersomnia, you will have to report it separately with other ICD-10 codes. You will have to report insomnia with G47.0- (Insomnia) and hypersomnia with G47.1- (Hypersomnia).

Reminder: You cannot use G47.30 when your clinician identifies the condition as apnea not elsewhere classified (R06.81); Cheyne-Stokes breathing (R06.3); pickwickian syndrome (E66.2); or sleep apnea of newborn (P28.3). If your provider diagnoses obstructive sleep apnea (OSA), you report the condition with G47.33 (Obstructive sleep apnea [adult] [pediatric]).

Focus on These Basics Briefly

Documentation spotlight: Your provider will arrive at a diagnosis of sleep apnea based on a complete history and a complete evaluation of the patient. Some of the complaints that your clinician would most likely record in a patient with sleep apnea will include breathlessness during sleep, snoring, and difficulty in falling asleep and maintenance of sleep. The patients will also complain of daytime sleepiness and reduced productivity at work.

Some of the other findings that your clinician is most likely to document in these patients will include drowsiness, reduced ability to concentrate, slower reflexes, hypertension, and poor appetite. Many of these patients also complain of weight gain that is disproportionate to the food intake. They might also suffer from psychiatric problems such as depression, anxiety, and mood swings.

When your practitioner suspects sleep apnea, he will assess the patient for obstructive sleep apnea. He will check for obesity, craniofacial problems such as retrognathia (reduced size of the lower jaw), cleft palate, or changes to the dimension of the tongue and other soft tissues of the orophargyngeal region. He will also perform a nasal examination to check for any signs of obstruction.

Tests: When your clinician is assessing a patient for sleep apnea, some of the lab tests that he is most likely to order include blood tests such as hematocrit and hemoglobin counts, thyroid function tests, and tests for arterial blood gases (ABG). The ABG tests will help in determining the level of oxygen saturation and level of carbon dioxide in the blood. 

Apart from these blood tests, your clinician might also opt for oximetry, pulmonary function tests such as spirometry, diffusing lung capacity, and lung volume to check for any pulmonary problems that might be contributing to the apnea.

In addition, your clinician might encourage the patient to maintain a sleep journal to record sleep patterns and to check how disturbed the patient’s sleep cycle is.

Apart from these tests, your internist might opt for sleep studies and polysomnography to determine the patient’s sleep patterns and wakefulness.

Example: A 62-year-old male patient reports to your internal medicine specialist with complaints of restlessness during sleep, frequent arousal from sleep due to a gasping or choking sensation, and recent episodes of daytime sleepiness. He complains that these incidents are affecting his day-to-day schedules, and he has difficulties with concentration.

Your physician performs a comprehensive evaluation of the patient and suspects sleep apnea. He examines the patient’s oropharyngeal areas and the nasal passages but finds no signs of obstruction. Your physician notes that the patient is not obese.

He withdraws a blood sample and sends it to the lab for hematocrit and hemoglobin values. He also draws an arterial blood sample that he sends for analysis of blood gases. Imaging studies of the respiratory system do not show any abnormalities.

He decides to order a polysomnography (PSG) that records EEG, EOG, EMG, ECG, airflow, and oxygen saturation followed by maintenance of wakefulness (MOW) test the next day. Based on signs and symptoms and results of lab tests and the PSG and MOW, your clinician arrives at the diagnosis of sleep apnea.

What to report: You report the encounter with the patient using an appropriate E/M code. You report the diagnosis with 780.57 if you are using ICD-9 codes or report G47.30 with ICD-10 codes.