Health Information Management

Q&A: Coding for the incision and drainage of lacrimal sac

JustCoding News: Outpatient, May 5, 2010

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QUESTION: A physician intubated the nasolacrimal duct with a silicone stent and performed an incision and drainage (I&D) and curretage of the canaliculus lower lid. 

Note the following documentation:

Significant drainage and granular material was expressed from the left lower lid canaliculus and sent for culture. A #2 Bowman probe could be introduced into the left lower nasolacrimal duct without significant resistance. An 11 blade was used to make a stab incision into the canaliculus proximal to the punctum. A currette was introduced into the canaliculus to remove the material. A small incision was also made into the punctum to enlarge the punctum in order to fit the curette, and this area was drained as well. The nasal packing was removed. A Crawford tube was introduced into the superior nasolacrimal system and retrieved from beneath the inferior turbinate using the Crawford hook. The Crawford tube was then introduced into the inferior punctum and the inferior canalicular and nasolacrimal duct and also retrieved from under the inferior turbinate. The intubation with the silicone stent was passed with ease. A 7-0 Vicryl suture was used to close the areas where the canaliculus and punctum were incised. The metallic tips from the Crawford were cut, and a single square knot was used to tie the tubing.

The Crawford tube was then allowed to retract back into the nose. Anesthesia was reversed, and the patient was extubated without complication and returned to the recovery room in good condition having tolerated the procedure well. There were no complications.

I reported CPT code 68801 (dilation of lacrimal punctum, with or without irrigation) and code 68815 (probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent). But I'm not sure whether I should report code 68700 (plastic repair of canaliculi) for the I&D and curretage of the canaliculus lower lid.

ANSWER: CPT code 68700 (plastic repair of canaliculi) is not the correct code to report I&D of this duct. The lower lid canaliculus is also known as the lacrimal canaliculus and is directly next to the lacrimal sac. If the physician agrees and documents these facts, you should be able to report code 68420 (incision, drainage of lacrimal sac [dacryocystotomy or dacryocystostomy]).

Code 68815, which you used to report the insertion of the silicone stent, already includes the dilation of the lacrimal punctum because this would be necessary to insert the stent. Therefore, you should not report code 68801.

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at ssafian@embarqmail.com.

This answer was provided based on limited information submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.



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