Circadian Rhythm Sleep Disorder (CRSD) refers to sleep problems in which a person’s internal sleep-wake cycle does not line up with the times in their schedule when they need to be asleep or awake. Your body runs on an internal clock that causes you to feel sleepier during the night and more awake and alert during the day time. This natural sleep rhythm is known as the circadian rhythm. When this rhythm is disrupted, it can cause symptoms that range from daytime sleepiness to depression. One of the key features associated with CRSD is a continuous or occasional disruption of sleep patterns. The disruption results from either a malfunction in the “internal body clock” or a mismatch between the “internal body clock” and the external environment regarding the timing and duration of sleep. As a result of the circadian mismatch, individuals with these disorders usually complain of insomnia at certain times and excessive sleepiness at other times of the day, resulting in work, school, or social impairment. Taking adequate steps to get on a more regular sleep schedule can help alleviate these symptoms in the long run. When compared to other sleep problems, CRSDs do not affect the quality of your sleep, but may rather make you sleepy – especially at times when they need to be awake and make you awake when you need to sleep. Treatment for this condition involves a combination of medications and behavioral support. Sleep specialists or primary care physicians treating this condition can rely on established medical billing and coding companies to get the correct codes reported on their medical claims.

There are different factors that cause circadian rhythm sleep disorders. Conditions that normally influence sleep include – light, levels of physical activities, levels of melatonin, a sleep hormone and social activities. Disruptions of one or more of these factors can lead to this sleep disorder. Persons suffering from certain medical conditions like congestive heart failure or chronic obstructive pulmonary disease are more likely to experience a circadian sleep condition. Additional risk factors related to medical conditions include – chronic pain syndromes, dementia, hyperthyroidism and intellectual disability. In addition, consuming certain medications, people who travel overseas and shift workers can also have higher chances of suffering CRSD.

Types of Circadian Rhythm Sleep Disorder (CRSD)

Circadian rhythm sleep disorders are of different types. In fact, many classifications are based on when a person typically goes to sleep.

  • Advanced sleep phase disorder (ASP) – In most cases, middle-aged or older adults are more likely to suffer this condition. People with this disorder are an “early bird” or “morning lark”. Most people with ASP go to bed typically between 6 p.m. and 9 p.m. They also wake up early, usually between 2 a.m. and 5 a.m.
  • Delayed sleep phase syndrome (DSPS) – Reports suggest that an estimated 7-16 percent of adolescents and young adults have DSPS. People with DSPS often describe themselves as “night owls” as they have difficulty falling asleep at a “normal” bedtime but go to sleep late (2 AM or even later).
  • Irregular sleep-wake disorder (ISWD) – A person with ISWD may not sleep for an extended period of time. Instead, they may take brief naps throughout the day. It is characterized by at least three sleep episodes per day, which occur at varying times.
  • Non-24-hour sleep-wake disorder – Typically, people with this disorder have brains that do not recognize the lighting cues that signal circadian rhythms. People have varying, irregular sleep patterns. Also known as free running type, people with this problem have varying, irregular sleep patterns. Often, with this problem, your preferred sleep period changes daily, usually shifting 1-2 hours later each day. For unknown reasons, your internal “clock” tends to maintain a 25-hour “day”.
  • Jet-lag disorder – This is a temporary condition that affects people of all ages and occurs when a person travels from one time zone to another time zone. The body often has difficulty adjusting to the new time. The greater the difference between time zones, the more significant the symptoms are.
  • Shift work disorder – Changes in the timing of your work shift can cause a CRSD called shift work type. People with this condition experience serious difficulty in getting enough sleep in the day time to compensate for lost overnight sleep.

Typical Symptoms

A circadian rhythm sleep disorder can impact many aspects of your life. Each disorder type has unique symptoms. Most people with these sleep disorders have one or more of these symptoms. Some of the most common symptoms include –

  • Difficulty going to sleep
  • Difficulty staying asleep
  • Not feeling refreshed after sleeping

If left undiagnosed and untreated at the right time, this condition can lead to insomnia, depression, impaired work performance, stressed relationships and disrupted social schedules.

How to Diagnose and Treat Circadian Rhythm Sleep Disorder (CRSD)?

Generally, diagnosis of circadian rhythm sleep disorder is done by a sleep medicine specialist. The sleep specialist as part of the diagnosis will ask patients to maintain a sleep journal where they can note down the details of their sleep patterns like what time they went to sleep and the time they woke up from their sleep. People who have difficulties keeping an accurate sleep journal may opt for actigraphy. This technique uses a wrist monitor to measure periods of being awake and asleep. In addition, the sleep specialist may also recommend a sleep study which involves sleeping under observation. A patient may wear a heart monitor, a breathing monitor, or both during the sleep study. This helps a sleep medicine specialist to rule out heart- or breathing-related sleep disruptions.

Treatment for this condition may focus on addressing light and melatonin – the two main factors that affect sleep. Incorporating a series of changes to promote better sleep can help sufferers find relief. Treatment modalities for this condition involve a combination of medications and behavioral therapy. Medications like – Benzodiazepines, Estazolam, Flurazepam, Quazepam (Doral), Temazepam (Restoril) and Triazolam (Halcion) help regulate sleep wake cycles over-the-counter to enhance sleep. Non -benzodiazepine hypnotics are another class of medications that are prescribed to treat circadian rhythm sleep disorders. Apart from medications, behavioral therapy activities like – maintaining regular sleep times, avoiding naps, getting regular exercise, adjusting exposure to day light, performing quiet activities (like reading before going to sleep) and avoiding bright lights at night can help manage the symptoms of this condition. Bright light therapy is used to help advance or delay sleep through the use of a high intensity light box. This therapy helps in calibrating the circadian rhythm by having the user sit in front of the bright light box at appropriate times of the day (depending on the disorder being treated) for a varied amount of time (depending on doctor recommendations).

Sleep medicine specialists or other physicians who diagnose, screen and treat CRSD must carefully document the diagnostic tests and other procedures using the correct medical codes. Medical billing and coding services provided by established billing companies can help physicians in using the correct codes for their medical billing process.

In ICD-10, code G47 comes under the category of sleep disorders –

  • G47.2 – Circadian rhythm sleep disorders
  • G47.20 – Circadian rhythm sleep disorder, unspecified type
  • G47.21 – Circadian rhythm sleep disorder, delayed sleep phase type
  • G47.22 – Circadian rhythm sleep disorder, advanced sleep phase type
  • G47.23 – Circadian rhythm sleep disorder, irregular sleep wake type
  • G47.24 – Circadian rhythm sleep disorder, free running type
  • G47.25 – Circadian rhythm sleep disorder, jet lag type
  • G47.26 – Circadian rhythm sleep disorder, shift work type
  • G47.27 – Circadian rhythm sleep disorder in conditions classified elsewhere
  • G47.29 – Other circadian rhythm sleep disorder

People with circadian rhythm sleep disorders need to maintain a normal sleep schedule to get enough sleep. However, for those who do not sleep enough, complications such as depression, disrupted social schedule, insomnia, and difficulty in concentrating at work can occur. In addition, people who make adequate changes to their sleep routines and light exposure are more likely to resume a more normal sleep schedule.

As allergy and sleep medicine medical billing and coding is challenging and time-consuming, physicians can consider hiring medical coding services. This would ensure accurate reporting of diagnostic details and help avoid delayed / denied claims.