2025 ICD-10-CM code F13.182
Sedative, hypnotic, or anxiolytic (SHA) abuse with SHA-induced sleep disorder.
Medical necessity is established by demonstrating a direct causal link between SHA abuse and the sleep disorder, impacting the patient's health and well-being. Documentation should clearly articulate the need for intervention and treatment.
The clinician must document the patient's history, signs and symptoms, personal and social behavior, and conduct a physical examination. A sleep study may be necessary.Treatment involves counseling, sleep hygiene education, medication, and extended continuing care.
- Mental, Behavioral and Neurodevelopmental disorders (F01-F99)
- Mental and behavioral disorders due to psychoactive substance use (F10-F19)
In simple words: This diagnosis means someone is abusing medications meant to calm them down or help them sleep, and this abuse is causing them to have problems with their sleep.
This code signifies excessive consumption of sedative, hypnotic, or anxiolytic substances, regardless of physical or mental health consequences, leading to drug-induced sleep disturbances.It includes difficulties falling asleep, staying asleep, nighttime restlessness, excessive daytime sleepiness, fatigue, irritability, lack of concentration, and depression. General symptoms of SHA abuse may also present, such as anxiety, memory loss, gait disturbances, lack of coordination, and behavioral problems.
Example 1: A patient with a history of anxiety disorders presents with complaints of insomnia, daytime sleepiness, and irritability.Upon further evaluation, it is revealed that the patient has been excessively using prescribed benzodiazepines for longer than intended., A patient arrives at the emergency room exhibiting slurred speech, lack of coordination, and confusion. They admit to taking more sleeping pills than prescribed due to ongoing insomnia.A toxicology screen confirms the presence of high levels of a hypnotic drug., An individual seeks help for substance abuse, reporting long-term misuse of over-the-counter sleep aids.They describe struggling with daytime fatigue, difficulty concentrating at work, and increased anxiety, despite continued use of the sleep aids.
Documentation should include evidence of SHA abuse (amount, frequency, duration), specific sleep disturbances, impact on daily functioning, presence of other SHA-related symptoms, and any related mental or physical health conditions.
- Specialties:Addiction Medicine, Psychiatry, Sleep Medicine, Primary Care
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, Telehealth Provided in Patient’s Home,Telehealth Provided Other than in Patient’s Home