Primary Care Coding Alert

Question: The physician performs a level-two E/M on a new patient with sleep issues. The medical record indicates that the patient had obstructive sleep apnea caused by excess weight. Should I use ICD-9 code 780.51 to represent this condition? Minnesota Subscriber Answer: Code 780.51 (Insomnia with sleep apnea, unspecified) is not specific enough for your scenario. Use 780.51 when the physician cannot (or has not yet) determined the cause of the condition. Because the physician noted that the patient had obstructive sleep apnea, you should instead choose 327.23 (Obstructive sleep apnea [adult] [pediatric]). On the claim, report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history, an expanded problem focused examination, straightforward medical decision-making) and 327.23.