Documenting and Coding Insomnia – An Overview of the Condition

Documenting and Coding Insomnia – An Overview of the Condition

Insomnia is difficulty falling asleep or staying asleep, even when a person has the chance to do so. Read about this condition and its diagnosis codes.

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Regarded as a common sleep complaint that affects millions of people worldwide, insomnia refers to difficulty falling asleep, hard to stay asleep or cause a person to wake up too early and not be able to get back to sleep.

People may feel tired when they wake up. The sleep condition can not only deplete a person’s energy level and mood, but also affect his/her health, work performance and quality of life. Insomnia commonly leads to daytime sleepiness, lethargy, and a general feeling of being unwell, both mentally and physically. Generally, many adults may experience short-term (acute) insomnia – which is usually the result of stress or a traumatic event and lasts for several days or weeks. On the other hand, long-term (chronic) insomnia may last for a month or more. In most cases, insomnia may be the primary problem, or it may be associated with other medical conditions or medications. Incorporating simple changes in your daily habits can often help manage this condition in an effective manner. For correct clinical documentation of this common sleep disorder, physicians can depend on medical billing and coding companies. Experienced outsourcing companies that provide medical billing services can provide the required support to physicians treating this sleep condition.

According to the American Psychiatric Association (APA), insomnia is the most common of all sleep disorders. The APA suggests that about one-third of all adults report insomnia symptoms. However, between 6 to 10 percent of adults have symptoms severe enough for them to be diagnosed with insomnia disorder. The condition is also associated with a higher risk of developing chronic diseases.

Causes and Types of Insomnia Insomnia can be caused by physical and psychological factors. In some cases, an underlying medical condition can cause chronic insomnia, while

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transient insomnia may be due to a recent event or occurrence. Common causes include – 

Disruptions in

circadian

rhythm

–

jet

lag,

job

shift

changes,

environmental noise, extreme heat or cold 

Psychological issues – bipolar disorder, depression, anxiety disorders, or psychotic disorders



Medical

conditions

–

chronic

pain,

chronic

fatigue

syndrome,

congestive heart failure, angina, acid-reflux disease (GERD), chronic obstructive pulmonary disease, asthma, sleep apnea, Parkinson’s and Alzheimer’s diseases, hyperthyroidism, arthritis, brain lesions, tumors, stroke. 

Hormones – estrogen, hormone shifts during menstruation.



Other factors – sleeping next to a snoring partner, parasites, genetic conditions, overactive mind, pregnancy.

As people get older, they may experience changes in sleep patterns, activity levels and high use of medications. Nearly everyone experiences occasional sleepless nights. However, the risk of this condition increases if you are a woman, if you are above 60 years of age, or if you experience a lot of stress and irregular work schedule.

Insomnia is generally classified into four different types 

Transient insomnia – This type occurs when symptoms last up to three nights.



Acute insomnia – Also called short-term insomnia, the symptoms of this type persist for several weeks.



Chronic insomnia – This chronic type of insomnia lasts for months, and sometimes years. According to the National Institutes of Health, the majority of chronic insomnia cases are side effects resulting from another primary problem.

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

Hypersomnia – This type is characterized by recurrent episodes of excessive

daytime

sleepiness

or

prolonged

nighttime

sleep.

Hypersomnia may be caused by another sleep disorder (such as narcolepsy or sleep apnea), dysfunction of the autonomic nervous system, or drug or alcohol abuse. In some cases it results from a physical problem, such as a tumor, head trauma, or injury to the central nervous system.

Symptoms Insomnia itself may be a symptom of an underlying medical condition.

However, there are other symptoms that are associated with the condition 

Difficulty falling asleep at night



Waking up during the night



Waking up too early



Not feeling well-rested after a night's sleep



Irritability, depression or anxiety



Increased errors or accidents



Difficulty paying attention, focusing on tasks or remembering



Daytime tiredness or sleepiness



Ongoing worries about sleep

Diagnosing and Treating Insomnia Diagnosis may begin with a physical examination to look for signs of medical problems that may be related to insomnia. Physicians may screen patients for psychiatric disorders and drug and alcohol use. Sleep specialists may conduct a detailed sleep habit review wherein they will ask questions about the patient's sleep pattern and his/her level of daytime sleepiness. Patients may also be asked to keep a sleep diary for a couple of weeks to understand their sleeping patterns. In some cases, a blood test may be done to check

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for thyroid problems or other conditions that may be associated with poor sleep. If the cause of insomnia is not clear, or have signs of another sleep disorder (such as sleep apnea or restless legs syndrome) patients may need to

spend

a

night

at

a

sleep

center.

Other

additional

tests

like

polysomnograph (sleeping test that records sleep patterns), actigraphy(uses a wrist-worn device called an actigraph to measure movement and sleepwake patterns) may be performed. Tests may also be performed to monitor and record a variety of body activities while you sleep, including brain waves, breathing, heartbeat, eye movements and body movements.

In most cases, making significant changes in the sleep habits and addressing other associated issues like stress, medical conditions or medications, can help restore restful sleep for many people. If any of these self-care, individual measures do not work properly or give the expected results, sleep specialists may

recommend

other treatment measures like

cognitive

behavioral therapy, medications or both, to help improve relaxation and sleep. Cognitive behavioral therapy for insomnia (CBT-I) can help people control or eliminate negative thoughts and actions that keep them awake and recognize and change beliefs that affect their ability to sleep. CBT-I include - Stimulus control therapy, Relaxation techniques, Sleep restriction, Light therapy and remaining passively awake.

Sleep specialists or other specialists who diagnose, screen and offer treatment for different types of insomnia rely on reputable medical billing and coding companies for accurate documentation. ICD-10 Codes for diagnosing insomnia include G47.0 - Insomnia 

G47.00 - Insomnia, unspecified



G47.01 - Insomnia, due to medical condition



G47.09 - Other insomnia

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G47.1 - Hypersomnia 

G47.10 -Hypersomnia, unspecified



G47.11 - Idiopathic hypersomnia with long sleep time



G47.12 - Idiopathic hypersomnia without long sleep time



G47.13 - Recurrent hypersomnia



G47.14 -Recurrent hypersomnia, due to medical condition



G47.19 - Other hypersomnia

Insomnia is a real sleep disorder, and no matter what your age, insomnia usually is treatable. The key often lies in bringing changes to your daily routine during the day and when you go to bed. Prevention strategies include – staying active, avoiding large meals and beverages before bed, avoid trying too hard to sleep, limiting naps and sticking to a regular sleep schedule. The documentation task is important for doctors and healthcare facilities to get paid for the services rendered. The support of an experienced medical coding service provider could be invaluable to document insomnia.

Billers

and

coders

in

reliable

medical

coding

outsourcing

companies would ensure accurate reporting of diagnostic detail, which is indispensable for timely and appropriate reimbursement.

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