Nasal Punctum-Nasolacrimal Duct Dilation and Probing with or without Irrigation

Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Abstract:

Dilation of nasolacrimal punctum and probing of nasolacrimal duct, with or without irrigation are useful treatments when mechanical, inflammatory or infectious processes cause or contribute to obstruction of normal tear drainage resulting in epiphora (excess tearing) or persistent infection.

The most common cause of obstruction in adults is primary acquired nasolacrimal duct obstruction (PANDO). Epiphora (excess tearing) is the most common symptom of obstruction of the nasolacrimal system. Tear duct obstruction in adults can occur at any point in the nasolacrimal system including the punctum, nasolacrimal sac, and nasolacrimal duct. Obstruction most commonly occurs in the puncta or nasolacrimal duct and sac. Disease of the canalicular system is less common.

It is important to differentiate between chronic epiphora, acute epiphora, and normal tearing. Chronic epiphora results from a persistent or continuous disorder and usually presents a more challenging clinical problem. Acute epiphora usually results from irritative ocular conditions such as corneal foreign bodies, allergic conjunctivitis, environmental factors such as wind, pollen, eyestrain, emotional stress, and sleep deprivation. One of the most common causes of excess tearing in older adults is dry eye syndrome. Acute epiphora usually resolves with treatment of the associated disorder and may not require dilation or probing.

Before dilation and/or probing are performed, pre-punctal disturbances of ocular surface tear flow such as lid malposition and non-obstructive causes (allergy, dry eye, blepharitis, etc.) should be excluded. Tear production measurement (Schirmer test), and tear break-up time (TBUT) can indicate insufficiency or instability of tears, which can cause or contribute to epiphora. Dye disappearance testing (sodium fluorescein), Jones dye testing or saccharine testing can be used to exclude significant obstruction and/or help identify the site and degree of obstruction.

If after the history, physical examination (including slit lamp), and other appropriate non-invasive tests have been completed, the site of obstruction is suspected to be at or distal to the punctum, dilation may proceed. Local anesthetic is instilled, and then the punctum is gradually dilated using probes of increasing size. If simple dilation fails to establish patency, lacrimal probing may be performed by passing a malleable wire probe through the punctum, into the canaliculus, lacrimal sac and down the nasolacrimal duct until patency is established. Irrigation may be used during both dilation and probing.

For patients in whom nasolacrimal duct probing has failed, further surgical treatment is available.

Punctal dilation and lacrimal duct probing is contraindicated in the following circumstances:

• Anatomic malformations in the lacrimal duct or bony lacrimal canal;
• Recurrent episodes of active dacryocystitis;
  
  
• Post-traumatic strictures with bony narrowing;
  
  
• Tumor of the lacrimal sac.

For procedural illustration for probing of nasolacrimal duct, please refer to Current Procedural Terminology (CPT) 2021, pg 502.

Indications:

Nasolacrimal punctal dilation and nasolacrimal duct probing may be reasonable and necessary when obstruction at or distal to the lacrimal puncta is reasonably suspected to be causing or contributing to the patient's symptoms (usually excessive tearing (epiphora) or chronic dacryocystitis), and when such measures are required to alleviate the patient's symptoms and reduce the likelihood of infection or damage to the lacrimal drainage apparatus.

Probing of the nasolacrimal duct and/or dilation of the nasolacrimal punctum can be carried out for any of the following indications:

• Epiphora (excessive tearing) due to acquired obstruction within the nasolacrimal sac and duct;
  
  
• A mucocele of the lacrimal sac;
  
  
• Chronic dacryocystitis or conjunctivitis due to lacrimal sac obstruction;
  
  
• Lacrimal sac infection that must be relieved before intra-ocular surgery.

Limitations:

1. Payment for these procedures for treatment of epiphora is limited to patients whose medical records indicate they have first undergone a thorough lacrimal evaluation that includes at least the following:
   
   • Consideration by history and physical examination (including slit lamp), of likely pre-punctal and/or non-obstructive causes for epiphora such as disturbances of ocular surface tear flow by lid malposition, allergy, dry eye, blepharitis; and
   • Non-invasive testing to diagnose punctal or post-punctal obstruction and to identify the site and degree of obstruction, such as by using dye disappearance testing when appropriate; followed by
   • Initiation of appropriate treatment.
2. Separate reimbursement for tear production measurement (Schirmer test), tear break-up time (TBUT), dye disappearance testing (sodium fluorescein), Jones dye testing or saccharine testing is not available. These are considered part of a general opthalmological examination or E&M service.
3. Reimbursement for CPT 68801 and 68810 is limited to only the specific eye(s), right or left, for which these procedures are considered reasonable and necessary. Payment for performance of a bilateral procedure may be denied or reduced to a unilateral procedure if medical record documentation fails to support that both eyes had qualifying signs or symptoms and had undergone proper pre-procedural evaluation as described above.
   
   
4. Punctal dilation and lacrimal duct probing are not indicated for dacryocystolithiasis.
   
   
5. CPT 68810, 68811 or 68815 are primarily pediatric procedures, and are only rarely required in adults, whereas CPT 68840 is more commonly performed in the adult population. The submitted CPT code must reflect the true extent of a reasonable and necessary procedure. Thus, if it is only medically necessary to dilate the punctum or probe the canaliculi it would be inappropriate to submit 68810, for example.
   
   
6. Provision of any of these services is subject to state regulations, and individual providers’ scopes of practice.

N/A

N/A

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Medical record documentation should indicate that before these procedures were performed an adequate lacrimal work-up and non-invasive evaluation were completed. Such an evaluation should include at minimum:

• Consideration by history and physical examination (including slit lamp), of likely pre-punctal and/or non-obstructive causes for epiphora such as disturbances of ocular surface tear flow by lid malposition, allergy, dry eye, blepharitis; and
• Non-invasive testing to diagnose punctal or post-punctal obstruction and to identify the site and degree of obstruction, such as by using dye disappearance testing when appropriate; followed by
• Initiation of appropriate treatment.

The medical record must contain a clear procedure note documenting the anesthesia, dilation, probing and irrigation procedures and indicating the results, such as: the likely site(s) of obstruction and whether and to what degree patency has been confirmed /established, or persistent obstruction remains.


Not applicable

Effective antibiotic treatments exist for infection and definitive surgical treatments are available for most obstructive disorders of the nasolacrimal system. While it is recognized that some patients may
occasionally require more frequent treatment, the majority of patients who do qualify for treatment will rarely need it more than twice per year.

Claims from providers who perform and bill for these procedures more frequently than their peers, especially without having documented a clinical and non-invasive evaluation indicating that pre-punctal and non-obstructive causes of epiphora have been considered, excluded and/or treated, may be subject to review and/or denial.

CPT 68810, 68811 or 68815 are primarily pediatric procedures, and are only rarely required in adults, whereas CPT 68840 is more commonly performed in the adult population. Providers with unusually frequent billing of 68810 may be subject to review. The submitted CPT code must reflect the true extent of a reasonable and necessary procedure. Thus, if it is only medically necessary to dilate the puncta or probe the canaliculi it would be inappropriate to submit 68810, for example. Claims for 68810 will be downcoded to 68840 or 68801, or denied if the medical record fails to demonstrate medical necessity and adequate documentation according to the requirements of this policy.

This bibliography presents those sources that were obtained during the development of this policy. National Government Services is not responsible for the continuing viability of Web site addresses listed below:

Ballard EA. Excessive tearing in infancy and early childhood. Postgraduate Medicine. 2000:107(6):149-154.

Camara JG. Nasolacrimal Duct Obstruction. http://emedicine.medscape.com/article/1210141. Accessed 02/14/2011.

Nasolacrimal Duct Obstruction Handbook of Ocular Disease Management. Chronic Epiphora. http://www.nevoptom,com/handbook/sectlj.html. Accessed 02/14/2011.

Lee DA, Higginbotham EJ. Clinical Guide to Comprehensive Ophthalmology. 1999. Thieme Publishing Group (NY, Stuttgart);1999;107-116.

Ophthalmologic Disorders. Chapter 93: Disorders of the Lacrimal Apparatus. Dacryostenosis. In: The Merck Manual of Diagnosis and Therapy.

Reed K. Diseases and Disorders of the Lacrimal System. Course Notes 1999. Ocular Disease and Therapeutics I, Nova Southeastern University College of Optometry. http://www.nova.edu/-kimreed/LACRIMAL.htm

Royal College of Ophthalmologists Guidelines: Management of Epiphora. http://www.site4sight.org.uk/Quality/Rgov/Guidelines/Epiphora.htm. Accessed 02/14/2011.

Spotten D, et al. Atlas of Clinical Ophthalmology. 2nd ed. Mosby Inc. (London, Philadelphia); 2000:20-24.

Yanoff M, Duke J. Orbit and Lacrimal Gland: The Lacrimal Drainage System. In: Ophthalmology. Mosby, Inc. (London, Philadelphia). 1998;7:17.7-17.8.

Yanoff M, Duker JS. Ophthalmology. 2nd ed. Mosby, Inc. 2004.

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