Primary insomnia
ICD-10 F51.01 is a billable code used to indicate a diagnosis of primary insomnia.
Primary insomnia is a sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early and not being able to return to sleep, occurring at least three times per week for at least three months. This condition is not attributable to other sleep disorders, medical conditions, or substance use. Patients often report daytime impairment, including fatigue, mood disturbances, and cognitive difficulties. The etiology of primary insomnia can be multifactorial, involving psychological factors such as stress, anxiety, and depression, as well as behavioral factors like poor sleep hygiene. Treatment typically involves cognitive-behavioral therapy for insomnia (CBT-I), lifestyle modifications, and, in some cases, pharmacotherapy. Accurate diagnosis and coding are crucial for effective treatment and management, as primary insomnia can significantly impact a patient's quality of life and overall health.
Detailed sleep history, including sleep patterns, duration, and quality; results from sleep studies if applicable.
Patients presenting with chronic insomnia complaints, referrals for sleep studies, and management of insomnia in the context of other sleep disorders.
Ensure comprehensive documentation of all sleep-related symptoms and any comorbid conditions that may affect sleep.
Assessment of psychological factors contributing to insomnia, including mental health history and current medications.
Patients with insomnia related to anxiety, depression, or other mood disorders.
Document the relationship between mental health conditions and sleep disturbances to support the diagnosis.
Used to evaluate sleep disorders, including insomnia.
Results of the sleep study must be documented to support diagnosis.
Sleep specialists should ensure comprehensive reporting of findings.
Primary insomnia occurs independently without any underlying medical or psychiatric condition, while secondary insomnia is caused by other factors such as medical conditions, medications, or mental health disorders.
