Primary Care Coding Alert

Question: A mother brought her toddler in with a chief complaint of sleeping problems. The FP performed a physical but could not find any problems (such as otitis media, etc.), and the patient's history was not conclusive of night terrors or nightmares. The FP identified the main problem as poor bedtime routines and night-time feeding. We used 307.40 (Nonorganic sleep disorder, unspecified) but were denied because it is a mental-health code. What other diagnosis code can we use?

Nevada Subscriber

Answer: Diagnosis code 307.40 is listed under the Mental Disorders section of the ICD-9 manual. Is this really a mental disorder, or is this simply sleeplessness due to bad night-time habits? Based on your description of the situation, it would seem the latter is true.

Accordingly, one coding option is 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 child couldn't sleep. You don't want to label him with insomnia (780.51 or 780.52), since that was not the doctor's ultimate assessment.

When billing this claim, make sure you do not use a preventive medicine code. Although the doctor did a physical and should be paid for his or her work, you will get denied billing a preventive medicine CPT code with a sign and symptom ICD-9 code. Instead, 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 there is 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 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) attached, linked to 780.50. You may have to send a report with the claim if you decide to bill it this way; however, from the sound of it, the office visit may cover all the work done.