ICD-10 Coding for Night Terrors(F51.4)
Complete ICD-10-CM coding and documentation guide for Night Terrors. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Night Terrors
F51.0-F51.9Primary Range
Sleep disorders not due to a substance or known physiological condition
This range includes various sleep disorders, with F51.4 specifically for night terrors.
Key Information: ICD-10 code for night terrors
Essential facts and insights about Night Terrors
Primary ICD-10-CM Code for night terrors
Decision Criteria
clinical Criteria
- Episodes occur during NREM sleep with autonomic signs and no recall.
coding Criteria
- Differentiate from nightmare disorder by confirming lack of recall and autonomic signs.
documentation Criteria
- Document specific symptoms and timing of episodes.
Applicable To
- Recurrent episodes of partial arousal from NREM sleep
- Autonomic hyperactivity
- Amnesia for the event
Clinical Validation Requirements
- Polysomnography showing NREM stage 3/4 arousal
- Absence of EEG evidence of seizures
Code-Specific Risks
- Confusing with nightmare disorder (F51.5)
- Omitting documentation of autonomic signs
Coding Notes
- Ensure documentation specifies NREM arousal and lack of recall to differentiate from nightmares.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Night Terrors to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code F51.4.
Impact
Clinical: Leads to misdiagnosis and inappropriate treatment., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials.
Mitigation Strategy
Use specific terminology like 'NREM arousal'., Include detailed symptom descriptions.
Impact
Reimbursement: Incorrect coding can lead to claim denials., Compliance: May result in compliance issues during audits., Data Quality: Affects the accuracy of patient records.
Mitigation Strategy
Ensure documentation specifies NREM arousal and lack of recall.
Impact
Failure to document NREM stage can lead to incorrect coding.
Mitigation Strategy
Ensure all documentation includes specific sleep stage details.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Night Terrors, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Night Terrors
Use these documentation templates to ensure complete and accurate documentation for Night Terrors. These templates include all required elements for proper coding and billing.
Child with night terrors
Specialty: PediatricsRequired Elements
- Chief Complaint
- History of Present Illness
- Physical Exam
- Polysomnography Results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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