Patient presents with complaints of chronic insomnia, characterized by difficulty initiating sleep, difficulty maintaining sleep, and early morning awakenings, impacting daytime functioning.  Symptoms have persisted for over three months, occurring at least three nights per week.  Patient denies any underlying medical conditions such as sleep apnea, restless legs syndrome, or periodic limb movement disorder contributing to the sleep disturbance.  Review of systems negative for significant findings.  Mental health screening reveals no current diagnosis of depression, anxiety, or other psychiatric disorders that could primarily account for the insomnia.  Sleep hygiene practices were reviewed, and patient reports inconsistent adherence to a regular sleep schedule, excessive caffeine intake, and frequent daytime napping.  Current medications include (list medications).  No known drug allergies.  Objective findings include reports of fatigue, daytime sleepiness, and difficulty concentrating.  Based on patient history, clinical presentation, and diagnostic criteria according to the International Classification of Sleep Disorders (ICSD), a diagnosis of Primary Insomnia is made.  Treatment plan includes cognitive behavioral therapy for insomnia (CBT-I), sleep hygiene education, and potential consideration of short-term pharmacotherapy for insomnia if CBT-I is insufficient.  Patient education provided on sleep hygiene practices, stimulus control therapy, and sleep restriction therapy.  Follow-up scheduled in four weeks to assess treatment response and adjust plan as needed.  ICD-10 code F51.01 (Insomnia, nonorganic, unspecified) is assigned.  Medical billing codes for evaluation and management (E M) services will be determined based on time spent and complexity of medical decision making.