Sleep apnea can occur when the upper airway becomes blocked repeatedly during sleep, reducing or completely stopping airflow. The article details the documentation guidelines for this condition using the correct ICD-10 codes.

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How to Diagnose &
Document Sleep Apnea
Using ICD-10 Codes
Sleep apnea can occur when the upper airway
becomes blocked repeatedly during sleep,
reducing or completely stopping airflow. The
article details the documentation guidelines for
this condition using the correct ICD-10 codes.
Outsource Strategies International

2. www.outsourcestrategies.com 918-221-7769
Sleep apnea is a common and serious sleep disorder in which an individual’s
breathing repeatedly stops and starts during sleep. People with this
condition snore loudly and will feel tired even after a full night's sleep. A
person suffering from this condition will unknowingly stop breathing
repeatedly throughout their sleep. The involuntary pause in breathing can
result either from a blocked airway or a signaling problem in the brain. Once
the airway is opened or the breathing signal is received, the person may
snort or awaken completely with a sensation of gasping, smothering, or
choking. The condition can be caused by one’s physical structure or other
medical conditions such as – obesity, large tonsils, premature birth, heart or
kidney failure, endocrine disorders, neuromuscular disorders and other
genetic syndromes. There are different types of sleep apnea and the main
types include - obstructive sleep apnea, central sleep apnea and complex
sleep apnea. Reports suggest that approximately 18 million Americans suffer
from this condition, but only 20 percent have been diagnosed and treated.
Untreated sleep apnea can lead to several serious health complications such
as heart disease and depression. It can leave a person feeling drowsy
thereby increasing the risk of accidents while driving or working. Treatment
for this condition mainly depends on the specific causes and the level and
type of apnea. The main goal of treatment is to normalize breathing during
sleep. As the coding and documentation for sleep apnea is nuanced and
complex, most physician practices rely on medical coding outsourcing to
meet their medical billing and coding requirements.
In most cases, patients suffering from sleep apnea may be unaware about
their symptoms. The signs and symptoms would depend on the type of sleep
apnea a person is suffering from. Common signs and symptoms include -
 Loud snoring (usually more prominent in obstructive sleep apnea)
Signs and Symptoms

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 Episodes of breathing cessation during sleep (witnessed by another
person)
 Restless sleep or insomnia
 Morning headache
 Irritability
 Heartburn
 Excessive daytime sleepiness and fatigue (hypersomnia)
 Decreased libido and erectile dysfunction
 Awakening with a dry mouth or sore throat
 Attention problems
 Abrupt awakenings accompanied by shortness of breath
Initial diagnosis and evaluation of this sleep disorder will be based on the
individual signs and symptoms displayed by the patient. Sleep specialists will
ask questions about the sleep environment which would include typical sleep
schedule, breathing pattern and other body functions during sleep. They
may conduct different tests such as nocturnal polysomnography and home
sleep tests to detect the pattern of sleep apnea.
Mild cases of sleep apnea can be effectively managed by incorporating
healthy/positive lifestyle changes such as reducing body weight or quitting
the habit of smoking. For those who have nasal allergies, physicians may
recommend medications for the same. In some cases, if any of the above
measures don't improve the signs and symptoms, certain devices such as
Continuous Positive Airway Pressure (CPAP), oral appliances, Expiratory
Positive Airway Pressure (EPAP) and other airway pressure devices can help
open up a blocked airway. Surgery may be considered only as a last resort
after all the other treatments have failed.
How to Accurately Diagnose and Document Sleep Apnea

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Allergy and sleep medicine medical coding involves the use of specific
ICD-10 codes to document any such conditions, including sleep apnea.
Sleep medicine physicians who treat this condition rely on reputable
medical billing companies to code the condition accurately. ICD-10-CM
codes used to indicate a diagnosis of sleep apnea for reimbursement
purposes include –
 G47.3 - Sleep apnea
 G47.30 - Sleep apnea, unspecified
 G47.31 - Primary central sleep apnea
 G47.32 - High altitude periodic breathing
 G47.33 - Obstructive sleep apnea (adult) (pediatric)
 G47.34 - Idiopathic sleep related non-obstructive alveolar hypoventilation
 G47.35 - Congenital central alveolar hypoventilation syndrome
 G47.36 - Sleep related hypoventilation in conditions classified elsewhere
 G47.37 - Central sleep apnea in conditions classified elsewhere
 G47.39 - Other sleep apnea
There are several risk factors associated with sleep apnea which may include
unhealthy lifestyle habits, age, sex, family history and genetics. Healthy
lifestyle changes can reduce your risk for developing sleep apnea. In most
cases, self-care is the most appropriate way to deal or manage the condition
of sleep apnea. Incorporating self-care strategies such as quitting the habit
of smoking, reducing excessive body weight, regular physical exercise,
sleeping on your side or abdomen rather than on your back, avoiding the
intake of alcohol and certain medications such as tranquilizers and sleeping
pills and keeping the nasal passages open at night can help better control
this disorder.
ICD-10 Codes to Use