Internal Medicine Coding Alert

Question: A woman came in with a chief complaint of sleeping problems. The internist performed a physical but could not find any problems. The patient's history was not conclusive of sleep apnea or nightmares. The internist identified the main problem as poor bedtime routines and late-night eating. We used 307.40 (Nonorganic sleep disorder, unspecified), but our payer denied the claim because the ICD-9 coding book lists 307.40 as a mental-health code. What other diagnosis code can we use?

Nevada Subscriber

Answer: Your situation reflects bad nighttime habits more than a mental disorder. In that case, consider using 780.50 (Sleep disturbance, unspecified). The classification for this category is "Symptoms, signs and ill-defined conditions." You are really coding for the symptom here, not the reason the woman couldn't sleep. You don't want to label her with a mental disorder or insomnia (780.51 or 780.52), since that was not the physician's ultimate assessment.
 
The doctor performed a physical and should be paid for his or her work. Report the appropriate-level office visit code (99201-99215) with 780.50. 
 
If this was the patient's yearly physical as well as a problem-focused exam (and you can provide documentation of both the preventive medicine visit and the work done beyond the preventive visit for the sleep disorder), bill V20.2 (Routine infant or child health check) for the preventive visit, and bill an E/M office visit with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended. Make sure to link 780.50 to the E/M code.