Find information on insomnia diagnosis, including ICD-10 codes (G47.00, G47.01, G47.09), DSM-5 criteria, clinical documentation tips, sleep study procedures, and treatment options. Learn about short-term and chronic insomnia, sleep disorder differential diagnosis, and medical billing guidelines for insomnia. Explore resources for healthcare professionals on proper coding and documentation of insomnia for accurate reimbursement and patient care.
Also known as
Insomnia
Difficulty falling or staying asleep, or non-restorative sleep.
Nonorganic sleep disorders
Sleep disturbances not attributed to physical or substance-induced causes.
Disorders of initiating and maintaining sleep
Problems with falling asleep and staying asleep.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is insomnia related to another mental disorder?
When to use each related code
| Description |
|---|
| Trouble falling or staying asleep |
| Insomnia due to medical condition |
| Insomnia due to medication |
Patient presents with complaints consistent with insomnia, characterized by difficulty initiating sleep, difficulty maintaining sleep, early morning awakenings, and non-restorative sleep. These symptoms have been present for approximately [duration] and occur [frequency] per week. Patient reports daytime impairment including fatigue, difficulty concentrating, irritability, and decreased performance at work/school. Patient denies sleep apnea symptoms such as snoring or witnessed apneas. Review of systems negative for restless legs syndrome. Medical history significant for [relevant comorbidities, e.g., anxiety, depression, chronic pain]. Current medications include [list medications]. Social history reveals [caffeine intake, alcohol use, nicotine use, sleep hygiene practices]. Mental status exam reveals [mood, affect]. Physical exam unremarkable. Differential diagnosis includes primary insomnia, insomnia due to a medical condition, insomnia due to a mental disorder, and substancemedication-induced insomnia. Assessment: Insomnia disorder, chronic. Plan: Discussed sleep hygiene recommendations including regular sleep schedule, creating a relaxing bedtime routine, and avoiding caffeine and alcohol before bed. Cognitive behavioral therapy for insomnia (CBT-I) recommended. Consider hypnotic medication for short-term symptomatic relief if CBT-I is unavailable or ineffective. Follow-up in [timeframe] to assess treatment response and adjust plan as needed. ICD-10 code: [appropriate ICD-10 code, e.g., G47.00, G47.01, F51.01].