In simple words: This code describes a sleep disorder caused by the continued use of sedatives, hypnotics, or anxiety-reducing medications.It's used when a person's sleep is significantly affected, impacting their daily life, but it's unclear if they are abusing or dependent on the medication.

Unspecified sedative, hypnotic, or anxiolytic use with sedative, hypnotic, or anxiolytic-induced sleep disorder refers to continuous, repeated use that threatens an individual’s health and negatively affects work, school, family, and social life with disturbed sleep. The provider does not document whether abuse or dependence is involved but does document SHA-induced sleep difficulties.

Example 1: A patient presents with difficulty falling asleep and staying asleep, along with daytime sleepiness and fatigue. They report regular use of anxiety medication. The provider determines the sleep problems are induced by the medication and uses F13.982 because there's no indication of abuse or dependence., An individual experiences significant daytime fatigue and irritability, affecting their work performance. They admit to using sleep aids regularly. A sleep study confirms a sleep disorder, and the physician documents it as medication-induced, leading to the use of F13.982., A patient reports chronic insomnia and daytime sleepiness, which impacts their social and family life. They use over-the-counter sleep medications frequently. Upon examination and review, the provider determines their sleep disorder is linked to the medication use and codes it as F13.982 in the absence of abuse or dependence.

Documentation should include the type of sedative, hypnotic, or anxiolytic used, the current severity of the sleep disorder, any complications, and the remission status. Details about the patient's sleep patterns, daytime symptoms, and impact on daily life should be noted. Evidence of medication use and any related medical evaluations (including sleep studies) should be included.