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Code appropriately for diagnosing, treating Demodex
Consider this diagnosis in patients who are unresponsive to infectious blepharitis treatment.
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Demodex has recently resurfaced as an etiology for blepharitis, especially in cases unresponsive to antibiotic treatment, according to Hom et al.
Knowledge of the appropriate procedure and diagnosis coding related to Demodex infestation is essential for accurate insurance billing for patients afflicted with this condition.
Coding for diagnosis
Mark R. Flora
Infestation of the eyelids, face, scalp and other body parts with the Demodex mites, D. folliculorum or D. brevis, is termed “demodicosis,” which has an ICD of 133.8. Blepharitis caused by these mites has an ICD of 373.6, “blepharitis, parasitic.” These codes may also be reported together on the same claim, listing the code for the cause (133.8), followed by the condition (373.6).
The clinical diagnosis of demodicosis or parasitic blepharitis may require obtaining a sample of the mite from the eyelid by scraping, epilation or both, placement on a slide and examination under a microscope; no staining of the sample is required. This laboratory technique may be used for identifying the mite as well as counting the organisms.
The CPT code for microscopic slide preparation is: 87177, “parasites, direct smear.” Another laboratory CPT code sometimes used in addition to direct smear is 99000, “specimen handling.” This is considered a “CLIA-waived” test, but you must still have a Clinical Laboratory Improvement Amendments (CLIA) number to bill Medicare and Medicaid. A CLIA number is not needed to bill other insurers.
Treatment not reimbursable
In-office treatment should consist of a warm, damp compress to soften the lid margin debris; removal of cylindrical collarets, dead mites, their byproducts and debris by scraping the eyelash base with a spatula; and application of 50% tea tree oil or 1% ivermectin ophthalmic ointment to the eyelid margins with a cotton-tipped applicator.
Lid débridement (no CPT) allows more effective contact of the applied drug to the live mites. In-office lid scraping can be repeated as needed to effectively reduce the mite population and improve clinical signs, but not symptoms. Have Medicare patients sign an Advance Beneficiary Notice of Noncoverage (ABN), indicating that this is a noncovered treatment and they will have to pay out-of-pocket.
Over-the-counter tea tree oil is considered the most effective treatment for demodicosis at this time. Tea tree oil soap and shampoo is prescribed for treating the scalp, face and other body parts and should be considered for patients with parasitic eyelid infestation, as they most assuredly have infestation elsewhere.
The goal of treatment is not to eradicate the mite but to decrease its numbers.
Lid débridement.
Images: Flora MR
Formulated tea tree oil, 50% ophthalmic ointment.
For parasitic blepharitis, a 50% sterile ophthalmic ointment can be formulated by a compounding pharmacist. About 2.5 cc are supplied in a 5-cc syringe, which must be kept frozen. It is prescribed in the same manner as for bacterial blepharitis: at bedtime, twice daily or three times daily. The ointment stings on application. The 2.5 cc should last about 3 months at a dose of once daily at bedtime. I purchase the filled syringes from the compounding pharmacy and then sell them to the patient as needed, about every 3 months.
Lang et al. recently reported that Demodex was found, by lash sampling, in 69% of both adults and children undergoing surgery for chalazia vs. 20% of controls. D. brevis was the dominant mite as compared to D. folliculorum as well as the dominant mite found in recurrences in 33% vs. 10% of patients with chalazia.
Office visits and laboratory tests are covered, but lid débridement and over-the-counter drugs are not.
Demodex seems to play a significant role in chalazia and its recurrence. In my experience, patients with chalazia almost always have infectious blepharitis, especially those with recurrences. Lang et al. did not indicate whether or not the patients in their study had signs of blepharitis, infectious or parasitic, which would give us a clue as to which patients with chalazia might benefit from treatment with tea tree oil. As we have seen, the signs of parasitic blepharitis can be confused with those of infectious blepharitis.
For now, if a patient is unresponsive to treatment for infectious blepharitis, we should look for Demodex and change treatment to lid débridement and formulated ophthalmic tea tree oil.