Primary Care Coding Alert

Question: A patient recently presented with pain in her hands that kept her awake at night, and the FP thought the patient might have arthritis and referred her to a rheumatologist for treatment. Our physician performed a level-three E/M, but we aren't sure which ICD-9 code to report because the physician wants us to code the inability to sleep as an underlying diagnosis. Is there an ICD-9 code for that?


Maryland Subscriber


Answer: Section 780.5 of the ICD-9 book, under the heading, -Symptoms, Signs and Ill-Defined Conditions,- lists a section for sleep disturbances. Code 780.52 (Insomnia, unspecified) is further described as -inability to maintain adequate sleep cycle.- This code may be most appropriate, depending on what the patient discussed with the physician during the office visit.

In addition, when you code for the joint pain, code 719.4x (Pain in joint) should have a fifth digit added to more accurately specify the site of the pain. For example, you-d report 719.44 to represent the pain in your patient's hand.

Remember that you shouldn't report an arthritis diagnosis because the physician merely suspects that the patient has arthritis, and you don't yet have confirmation of that diagnosis.