Treat Bedbug Bites in Two Creepy Steps

First treat the itch, then code the care.

By Susan Ward, CPC, CPC-H, CPC-I, CEMC, CPCD, CPRC, and Michelle A. Dick

Bedbug infestations can happen just about anywhere: houses, apartments, five-star hotels, college dorms, libraries, movie theaters, retail stores, school buses, and even hospitals. These bugs like to hitch a ride to new, dark, comfortable places. They are nocturnal bloodsuckers that feed just before dawn. Their bites are painless; however, the host may react with skin lesions that need inflammation relief.
Vacuuming, washing linens, and thoroughly cleaning won’t eliminate bedbugs, and neither will throwing out a mattress. The bug’s oval-shaped, flat body lends itself to hiding in the dark cracks and crevices of beds, furniture, baseboards, drawers, luggage, and even electrical outlet plates; they can hide and nest during the day and easily feed on an unsuspecting host at night.

Health Concerns

Many people are embarrassed by a bedbug infestation, and rather than calling an exterminator, they take matters into their own hands. They apply insecticides in their homes and on their beds without properly reading the labels, which can overexpose them to toxic chemicals. Other people (including landlords) call an expert to find out what insecticide to use and, hoping to save money, buy the insecticide on the Internet, and misuse it. This can be a health risk: Only a licensed professional should treat infestations with insecticides.
The good news is that bedbugs don’t spread infectious diseases from one person to another. You can’t catch malaria, hepatitis B or C, or HIV from a previous host. “… the potential for viral transmission from the beg bugs to humans is considered to be highly unlikely since the bed bugs lack not only the specific proteins necessary for hepatitis B virus replication, but also the T4 antigen on their cell surface that is required for human immunodeficiency virus replication,” according to the Skin & Aging website authors, Philip R. Cohen, MD, Jaime A. Tschen, MD, Floyd W. Robinson, BS, and James M. Gray, MD,
The main health concerns are that bites can cause distress, allergic reactions, itching (pruritus), and scratching that can lead to secondary infection. Bedbug bite symptoms may get progressively worse each time a person is bitten. Even if there are no symptoms for the first bite, the second time could result in marks. Strong allergic reaction to bedbug bites can turn into blisters.

How Do You Know if You Have Bedbugs?

Bites appear as circular, red, raised areas around the puncture that may vary in size and pattern. Sometimes they appear in a row. Rows of bites usually are caused by several bugs. They usually bite extremities and areas of the body that aren’t covered with clothing. Bedbug bites can be confused easily with mosquito or flea bites, so don’t jump to conclusions—if you suspect bedbugs, investigate further:

• Search the area where you just slept. Examine folds and creases in the mattress or sofa, box springs, curtain pleats, behind loose wallpaper, behind molding, and in drawers and luggage. Look on bed linens for dark-brown fecal spots and red blood spots.
• If you find an insect, put it in a plastic bag and compare it with a good reference image, or take it to an entomologist (a bug expert).
• Make sure you have a positive identification before you hire an exterminator. Exterminators can cost hundreds of dollars or more.

Bedbug Victims May Need Medical Attention

Sometimes bedbug treatment calls for medical attention. If an infection forms, antibiotic ointment can be used to treat the affected area. Stronger antibiotics, anti-itch creams, and antihistamines may be used for bites that take longer to heal. Oral antibiotics might be necessary if infection starts to spread.
Presenting Patient
An 18-year-old male presented with a three-week history of pruritic skin lesions on his hands, arms, feet, legs, and face. These multiple, 4 mm to 8 mm red papules appear in the morning and persist for several days. Prior to the occurrence of the lesions, he had moved into a college dorm.
Treatment
The patient’s pruritus reaction from the cutaneous bedbug bites was treated systemically and topically. He received loratidine 10 mg each morning and diphenhydramine elixir (12.5 mg to 50.0 mg, as needed) each evening. He also applied a lotion containing menthol 0.5 percent and camphor 0.5 percent (Sarna) several times each day. The lotion was refrigerated to provide additional itching relief.

CPT^® Codes

In this example, look to Evaluation and Management (E/M) CPT® codes. The medical decision making (MDM) in this situation would be low to straightforward, and if there was enough documentation you might be able to support moderate MDM. Coding depends on the service rendered, assuming this is an office/outpatient visit. For a new patient, this would be codes 99201-99203 for straightforward MDM, depending on the level of history and exam, or 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity for moderate MDM and supporting history and exam, which is less likely. For an established patient, the codes are 99212-99214, depending on the E/M and history/exam documented.

Diagnosis Codes

The diagnostic coding will be key to proper reimbursement. Choose diagnosis codes by site and reaction. Because the patient presented with bites on hands, arms, legs, and face, code choices would be:
910.4 Superficial injury of face, neck, and scalp except eye; Insect bite, nonvenomous,
without mention of infection
913.4 Superficial injury of elbow, forearm, and wrist; Insect bite, nonvenomous, without mention of infection
914.4 Superficial injury of hand(s) except finger(s) alone; Insect bite, nonvenomous, without mention of infection
916.4 Superficial injury of hip, leg, and ankle; Insect bite, nonvenomous, without mention of infection
917.4 Superficial injury of foot and toe(s); Insect bite, nonvenomous, without mention of infection
If the sites had been infected, you’d use the fourth-digit subdivision of “5” (Insect bite, nonvenomous, infected), rather than “4,” for categories 910-919.

HCPCS Level II Codes

Be familiar with the medications your provider has prescribed or administered during the visit. In this case the loratidine is an over-the-counter allergy medicine such as Alavert or Claritin. The diphenhydramine elixir would be written as a prescription, as would the lotion, which is to provide itching relief. In this case, do not code for any HCPCS Level II codes.

Treat the Infestation, Not Just the Bites

To resolve the problem, you must treat the skin reaction and eliminate the bug infestation. In our example, the patient returns to his dormitory and finds numerous bedbugs in the seams of his mattress. Small red and black spots and streaks were seen on the mattress, which were indicative of his blood and bug feces. He contacted his dormitory resident assistant (RA). His mattress was replaced, and the building manager called a bug exterminator to treat the infestation. Within a week, the dormitory was cleared and the skin lesions and pruritus were resolved.
In addition to calling an exterminator to apply insecticides, here are other suggestions that may help to eliminate the problem:

• Encase mattress in a bedbug-tight cover to trap bugs inside, so that bugs can’t feed and eventually will die. This treatment may not be successful because an adult bedbug can survive up to a year without a blood meal.
• When discarding a mattress or infested furniture mark it “This has bedbugs,” so that others don’t inadvertently use it and spread bugs.
• Move the bed away from shelving on walls.
• Coat the bed’s legs with a 2 inch (or more) wide band of Vaseline or mineral oil.
• Vacuuming can help to remove bedbugs and their eggs from surfaces, but won’t remove them all. Discard the vacuum’s contents in a sealed trash bag. Steam clean carpets, as well.
• Caulk cracks in the floor and walls, and glue down loose wallpaper. A professional exterminator frequently is necessary to treat the bedbug infestation.

ICD-10-CM tip:

Be sure to check your documentation now to be ready for ICD-10-CM. In coding for bedbug bites, it will still direct you to insect bite, (nonvenomous) of location, but your location must
be documented. For example:
S60.460x   Insect bite (nonvenomous) of right index finger
S60.461x   Insect bite (nonvenomous) of left index finger
 

Sources: Skin and Aging, volume 16, issue 11, November 2008, Philip R. Cohen, MD, Jaime A. Tschen, MD, Floyd W. Robinson, BS, and James M. Gray, MD, (http://skinandaging.com/content/diagnosis-bed-bug-bites) and WebMD (www.webmd.com/skin-problems-and-treatments/features/dont-lose-sleep-over-bed-bugs).

 
Susan Ward, CPC, CPC-H, CPC-I, CEMC, CPCD, CPRC, has more than 20 years of coding and billing experience. She works for a reconstructive plastic surgeon in Phoenix. She is a certified PMCC instructor for AAPC and was a member of the 2007–2009 AAPC National Advisory Board (NAB).

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