Primary Care Coding Alert

Also: refresh your memory of the sleep apnea codes.

A primary care practitioner (PCP) is often the first person to whom people turn when they can’t sleep, so it’s likely you’ve encountered such patient encounters that call for a variety of different codes.

If you could use a refresher, we’ve got you covered with this compilation of common codes you’re likely to come across for your easy reference. We’ve also added some great tips to help you use them accurately.

While not always a cause for real alarm or treatment, a person’s inability to sleep is important for doctors to monitor. Insomnia is a general term for a sleep disorder that involves difficulty falling asleep, staying asleep, or both, which results in inadequate quality or quantity of sleep. You will generally choose from either G47.0- (Insomnia) and F51.0- (Insomnia not due to a substance or known physiological condition). In the world of medical coding, however, not all insomnia is created equal.

For example, G47.0- is a code from Chapter 6: Diseases of the Nervous System (G00-G99), whereas F51.0- comes from Chapter 5: Mental, Behavioral, and Neurodevelopmental disorders (F01-F99). Knowing this should point you in the direction of the most accurate code. Consider the following choices from each code family:

G47.0- codes: These codes are a sort of catch-all group for use when notes are vague or the condition hasn’t been too deeply explored.

• G47.00 (Insomnia, unspecified)
• G47.01 (Insomnia due to medical condition)
• G47.09 (Other insomnia)

There are several specific types of insomnia for which payers will accept one of the general codes listed above in addition to the more specific code, if the patient exhibits both types. This shows the conditions listed in the note are different, despite “insomnia” being in the name. See also the note under G47.01 which instructs you to code also the associated medical condition. This is not to be confused with the next code family, which includes insomnia that’s due to a mental disorder.

F51.0- codes: These codes include a variety of more specific codes that relate to mental conditions.

• F51.01 (Primary insomnia)
• F51.02 (Adjustment insomnia)
• F51.03 (Paradoxical insomnia)
• F51.04 (Psychophysiologic insomnia)
• F51.05 (Insomnia due to other mental disorder)
• F51.09 (Other insomnia not due to a substance or known physiological condition)

These codes also feature a sizable list of Excludes2 notes, enabling you to pair F51.0- with other types of insomnia, including G47.0-.

Understand the Apnea Codes

Apnea is a common sleep disrupter. The more specific you can be about the patient’s sleep apnea, the better the chance for a positive outcome for the patient. Payers will appreciate your specificity on sleep apnea diagnosis code choices, too.

Condition refresh: Apnea is defined as the stoppage of respiratory airflow for at least 20 seconds.

When you choose an ICD-10 code for sleep apnea, you’ll head to the G47.3- (Sleep apnea) code set. From there, you’ll choose from the following apnea codes, depending on encounter specifics:

• G47.30 (Sleep apnea, unspecified)
• G47.31 (Primary central sleep apnea)
• G47.32 (High altitude periodic breathing)
• G47.33 (Obstructive sleep apnea (adult) (pediatric))
• G47.34 (Idiopathic sleep related nonobstructive alveolar hypoventilation)
• G47.35 (Congenital central alveolar hypoventilation syndrome)
• G47.36 (Sleep related hypoventilation in conditions classified elsewhere)
• G47.37 (Central sleep apnea in conditions classified elsewhere)
• G47.39 (Other sleep apnea)

When a patient has sleep apnea, one of the most common diagnoses is G47.30., This is because sleep apnea is so tricky to pin to a specific type according to Cynthia A. Swanson RN, CPC, CEMC, CHC, CPMA, AAPC ICD-10-CM Proficient, AAPC Fellow, senior manager of healthcare consulting at Seim Johnson, LLP in Omaha

Keep in Mind: “An unspecified code is assigned when neither the diagnostic statement nor the documentation provides enough information to assign a more specific code,” Swanson notes. You might have to use this code more often than you’d like. To mitigate the use of unspecified codes, try to get your providers and coders to understand that the more detail an encounter form carries, the less likely you are to have to use an unspecified code.

Don’t Forget About Newborn Apnea Codes

Newborn apnea is an entirely different set of codes. Newborns can have a variety of types of apnea, and ICD-10 allows you to report apnea in children to the 5th character. Again, the more specific, the better. “Apnea is a symptom that has many possible etiologies,” explains Donna Walaszek, CCS-P, billing manager, credentialing/ coding specialist for Northampton Area Pediatrics LLP in Northampton, Massachusetts.

This is why ICD-10 has assigned codes to several types of newborn apnea:

• P28.30 (Primary sleep apnea of newborn, unspecified)
• P28.31 (Primary central sleep apnea of newborn)
• P28.32 (Primary obstructive sleep apnea of newborn)
• P28.33 (Primary mixed sleep apnea of newborn)
• P28.39 (Other primary sleep apnea of newborn)
• P28.40 (Unspecified apnea of newborn)
• P28.41 (Central neonatal apnea of newborn)
• P28.42 (Obstructive apnea of newborn)
• P28.43 (Mixed neonatal apnea of newborn)
• P28.49 (Other apnea of newborn)

Pediatric coding alert: Evaluations for some pediatric conditions, such as autism spectrum disorder, include workup of co-occurring conditions like sleep disorder. If such an evaluation were to determine that a patient’s apnea has its origin not in something like obesity, but rather in the perinatal period, no matter the age at which the evaluation is performed, you’ll report a P28- code. Section I.C.16.a.1 of the ICD-10 Guidelines directs coders that “Chapter 16 codes may be used throughout the life of the patient if the condition is still present.”