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Scenario Week of April 22, 2010:
View Current Scenario

Assign the correct ICD-9-CM diagnosis code(s) and CPT procedure code(s) for the following case scenario:

This 14-month-old baby girl presents for nasolacrimal duct probing and dilation. The child has a history since birth of epiphora of both eyes, with worsening of the condition when she has a cold or is out on windy days. Besides tearing, she has crusting and drainage around the eyes. She was recently on antibiotics for conjunctivitis and increased mucous in the eye. Her parents have tried warm compresses and massage of the lacrimal sac, but that has not been helpful.

Preoperative diagnosis: Bilateral obstruction nasolacrimal ducts, right side greater than left

Postoperative diagnosis: Same

Procedure: Probing of nasolacrimal duct, bilateral

Operative procedure: The child was brought to the operating room and placed in the supine position on the operating table. General anesthesia was induced. A nasal speculum was used to examine the nose bilaterally. After dilation of the punctum on the left side, the left nasolacrimal system was probed. Methylene blue solution was injected through the nasolacrimal system and suctioned through the nose and noted to be patent. Attention was then turned to the right side. The right nasolacrimal system was dilated using a punctual dilator. Next, a 000 probe was inserted followed by successively larger probes until the nasolacrimal system was noted to be open. Methylene blue solution was injected through the right nasolacrimal system and suctioned through the nose and noted to be patent. Maxitrol ophthalmic solution was injected into the right punctum and noted to irrigate cleanly through the system. The child was discharged to the post-anesthesia care unit in good condition.

ICD-9-CM Code
743.65Specified congenital anomalies of lacrimal passages

The correct code is found in ICD-9-CM under the main term “Obstruction, obstructed, obstructive” and the subterms “nasolacrimal duct” and “congenital” which reference code 743.65. For this case, the condition is classified as congenital, rather than acquired. It is estimated that as many as six percent of all babies are born with an obstruction of the nasolacrimal duct, and the majority of them resolve without treatment by the time the child is one year old.

CPT Code
68811-50Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia

In the CPT index, search by the anatomic location, nasolacrimal duct. The term “probing” is not an option; however, a synonym or similar term “exploration” is listed and provides two options including one to perform the service under general anesthesia, which directs you to see code 68811. Because the procedure is performed bilaterally, CPT guidelines state to report modifier 50 Bilateral procedure, with this code. Code 68811 is primarily performed on pediatric patients and rarely used for an adult patient. Some payers may require documentation of previous tests to establish the diagnosis of nasolacrimal obstruction, such as the results of a fluorescein eye stain.

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