ICD-10 Coding for Increased Arousal When Starting Sertraline (Zoloft)
The appropriate ICD-10 code for increased arousal or agitation when initiating sertraline is R45.1 (Restlessness and agitation), which captures the acute behavioral symptom, while the underlying mental health condition requiring sertraline treatment should be coded separately as the primary diagnosis.
Primary Coding Approach
R45.1 (Restlessness and agitation) is the most specific code for the acute symptom of increased arousal or agitation that occurs as an adverse effect when starting SSRIs like sertraline 1, 2.
The underlying psychiatric diagnosis (e.g., F32.x for major depressive disorder, F41.x for anxiety disorders, F43.1 for PTSD) should be listed as the primary diagnosis, with R45.1 as a secondary code to document the treatment-related symptom 3.
Clinical Context for This Coding Scenario
Increased anxiety, agitation, and arousal are recognized initial adverse effects of SSRIs that commonly occur during treatment initiation or dose escalation, particularly in patients with underlying anxiety disorders 1.
This activation syndrome typically manifests within the first few weeks of SSRI treatment and can include symptoms of restlessness, agitation, increased arousal, insomnia, and akathisia 1, 2.
Sertraline-induced agitation has been documented in clinical trials and case reports, with one case describing acute agitation, diaphoresis, and altered mental status in the setting of rapid sertraline titration 2.
Alternative or Additional Codes to Consider
F19.99 (Other psychoactive substance use, unspecified with unspecified psychoactive substance-induced disorder) may be appropriate if the increased arousal represents a more severe medication-induced psychiatric syndrome, though this is less commonly used for routine SSRI activation 2.
G25.71 (Drug induced akathisia) should be used if the increased arousal specifically manifests as motor restlessness and an inability to sit still, which can occur with SSRIs 1.
F51.02 (Adjustment insomnia) may be added if the increased arousal is primarily manifesting as sleep disturbance, as sertraline is activating and commonly causes insomnia when initiated 1, 4.
Important Coding Caveats
Do not use codes for serotonin syndrome (G25.79 or T43.221A) unless the patient meets clinical criteria for true serotonin syndrome with the classic triad of neuromuscular excitation, autonomic instability, and altered mental status 2.
Avoid using codes for substance-induced mood disorder unless the activation syndrome has progressed to a full manic or hypomanic episode, which would warrant F19.14 (Other psychoactive substance abuse with psychoactive substance-induced mood disorder) 5.
The code R45.1 is preferable to vague codes like R45.89 (Other symptoms and signs involving emotional state) because it specifically captures the agitation component 1.