Primary insomnia

This code signifies a chronic sleep initiation or maintenance disorder that is not attributable to another mental disorder, medical condition, or substance use. Patients experience significant distress or impairment in social, occupational, or other important areas of functioning due to their sleep disturbance.

Apply this code when documentation clearly indicates a diagnosis of primary insomnia, meaning the sleep disturbance is the predominant complaint and is not better explained by another disorder. Supporting documentation should detail the chronicity of the sleep problem (e.g., occurring at least three nights per week for at least three months) and rule out other potential causes.

• Ensure documentation explicitly states "primary insomnia" or clearly rules out secondary causes.
• Do not use this code if the insomnia is a symptom of another underlying medical or psychiatric condition; instead, code the underlying condition.
• Consider co-coding with Z91.83 (Personal history of sleep-related problems) if applicable, but only if documented.