2025 ICD-10-CM code F51.9
(Active) Effective Date: N/A Revision Date: N/A Mental, Behavioral, and Neurodevelopmental disorders - Nonorganic sleep disorders Chapter V: Mental and behavioural disorders Feed
Unspecified sleep disorder not due to a substance or known physiological condition.
No specific modifiers are typically used with F51.9, but appropriate modifiers may be applicable depending on the context of care and services provided.
Medical necessity for the diagnosis and treatment of F51.9 is established by the presence of clinically significant sleep disturbance impacting daily functioning, ruling out any organic cause, and documenting the need for intervention based on patient symptoms and the potential impact on their quality of life.
The clinical responsibility includes obtaining a detailed patient history, performing a physical examination, ordering and interpreting relevant diagnostic tests (if necessary), establishing a diagnosis, developing a treatment plan, monitoring treatment effectiveness, and educating the patient about their condition and management strategies.
In simple words: This code means the patient isn't getting enough sleep, but it's not because of drugs or a medical problem. The doctor doesn't know the exact reason for the sleep problem. This could be due to stress, a noisy environment, working at night, life problems, or getting older.The patient might feel tired, irritable, unable to focus, sleepy during the day, and uninterested in things they usually enjoy. The doctor will figure out what's wrong and suggest treatment.
F51.9, Unspecified sleep disorder not due to a substance or known physiological condition, refers to inadequate sleep not caused by substance use or a known physical condition.The specific sleep disorder is not documented.Etiology may include work-related stress, environmental factors (temperature, noise), shift work, life stressors, and aging.Symptoms can include fatigue, irritability, difficulty concentrating, daytime sleepiness, and decreased interest in usual activities. Diagnosis is based on patient history, symptoms, behavioral assessment, and physical examination; polysomnography, EEG, and genetic testing may be used. Treatment depends on the underlying cause and may include anxiolytics, sedatives, melatonin, cognitive behavioral therapy (CBT) for sleep hygiene, relaxation/meditation, and exercise.
Example 1: A 45-year-old patient complains of chronic fatigue, difficulty falling asleep, and daytime sleepiness.Physical examination is unremarkable, and laboratory tests are normal. The patient reports significant work-related stress.F51.9 is used because no other specific sleep disorder is identified., A 68-year-old patient reports frequent awakenings during the night and difficulty returning to sleep. They have no other symptoms and have tried various over-the-counter sleep aids with limited success.The sleep study is non-diagnostic, but some sleep disturbance is present.F51.9 is used pending further investigation., A young adult presents with symptoms of insomnia and reports increased anxiety and stress due to upcoming exams.Their history suggests a likely non-organic basis. Further evaluation is needed to rule out underlying medical conditions contributing to sleep disturbance. F51.9 is utilized, reflecting the non-specific nature of the sleep disturbance at this time.
Detailed patient history focusing on sleep patterns, symptoms (fatigue, daytime sleepiness, etc.), and potential contributing factors (stress, environmental factors, etc.).Results of any physical examination, relevant laboratory tests (e.g., blood work to rule out medical causes), and sleep studies (polysomnography, if performed).Documentation of the treatment plan, including the specific interventions used.
** Consider using additional codes to specify associated conditions, such as anxiety or depression, if present.Always document the rationale for selecting F51.9 when other more specific sleep disorder codes are excluded.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Psychiatry, Sleep Medicine, Family Medicine, Internal Medicine
- Place of Service:Office, Hospital (Inpatient or Outpatient), Other outpatient settings