M79.601 - Pain in right arm

Clinical Definition

Sleep apnea is a sleep disorder where breathing repeatedly stops and starts during sleep. Obstructive sleep apnea occurs when throat muscles intermittently relax and block the airway, while central sleep apnea happens when the brain doesn't send proper signals to the muscles that control breathing.

Documentation Requirements

• Sleep study results (if available)

• Type specification:

  • Obstructive

  • Central

  • Mixed/Complex

  • NOS (Not Otherwise Specified)

• Severity level:

  • Mild

  • Moderate

  • Severe

• Associated conditions:

  • Obesity (if applicable)

  • Heart failure (if present)

  • Narcotic dependence (if relevant)

• Current treatment method:

  • CPAP usage

  • Oral appliance

  • Position therapy

  • Surgical intervention

Common Synonyms

• "Stops breathing while sleeping"

• "Choking/gasping during sleep"

• "Heavy snoring"

• "CPAP machine use"

• "Sleep disorder breathing"

Coding Conflicts

Excludes1:

• Sleep apnea of newborn (P28.3)

• Sleep disorders without sleep apnea

Excludes2:

• Pickwickian syndrome (E66.2)

• Sleep-related hypoventilation (G47.36)

Scribing.io Automation

The AI scribe automatically identifies:

• Sleep study mentions and AHI scores

• Treatment modalities discussed

• CPAP compliance data

• Associated comorbidities

• Severity descriptors
  The system flags incomplete documentation when severity or type specifications are missing, prompting for clarification in real-time.