087Y3DZ
Dilation Lacrimal Duct, Left to No Qualifier with Intraluminal Device, Percutaneous Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | 8 Eye |
| Operation | 7 Dilation |
| Body Part | Y Lacrimal Duct, Left |
| Approach | 3 Percutaneous |
| Device | D Intraluminal Device |
| Qualifier | Z No Qualifier |
Operation Definition
Expanding an orifice or the lumen of a tubular body part
Procedure Overview
This family covers procedures that widen a naturally narrow or obstructed passage in or around the eye, most commonly the tear drainage system. When the nasolacrimal duct or the small punctal openings at the inner eyelid become narrowed by scarring, chronic inflammation, or congenital underdevelopment, tears cannot drain normally into the nose, leading to persistent watering, discomfort, and sometimes recurrent infection.
A dilation procedure uses a probe, balloon catheter, or similar instrument to gently stretch the narrowed segment open, restoring normal tear flow without removing tissue or leaving a permanent implanted device behind. It is a frequently performed outpatient treatment, particularly in infants with congenital tear duct blockage and in adults with age-related or scar-related narrowing.
Anatomy & Axis Detail
Lacrimal Duct, Left
The left lacrimal duct is dilated when scarring or stenosis along its course, from the punctum through the canaliculus to the nasolacrimal duct proper, obstructs normal tear drainage and produces persistent watering of the eye. Probing with calibrated instruments is the traditional approach, particularly effective in congenital cases where a membranous obstruction at the valve of Hasner has failed to open spontaneously, while balloon catheter dilation is favored in adults with acquired fibrotic strictures, often as an alternative to bypass surgery. The duct's passage through the bony nasolacrimal canal limits the space available for instrumentation and raises the risk of mucosal trauma or false tracking if the stricture is tight or tortuous. Coding should reflect that the native duct lumen was enlarged in place, not replaced or bypassed.
Approach: Percutaneous
Percutaneous describes entry by needle or instrument puncture through the skin or mucous membrane to reach the site of the procedure, without cutting the tissue open or using a visualizing scope. It differs from Open in that the site itself is never exposed, and from Percutaneous Endoscopic in that no endoscope is used to see internal structures. Common examples include needle biopsies and injections.
Device: Intraluminal Device
Intraluminal Device denotes a single device, such as a stent or occlusion device, positioned within the lumen of a tubular body part like a vessel, duct, or airway to maintain patency or occlude flow. It carries no drug coating or radioactivity, distinguishing it from the drug-eluting, radioactive, and bioactive intraluminal device values, and from Extraluminal Device, which sits outside rather than inside the lumen.
Coding & Documentation
Coding requires documentation identifying the specific narrowed structure being opened, such as the lacrimal punctum, canaliculus, or nasolacrimal duct, along with the method used to achieve dilation, since the approach and any device used affect code selection. The note should confirm the intent was to expand an existing passage rather than create a new one or leave a stent permanently in place, which would shift the case toward Bypass or Insertion instead. A common error is coding a lacrimal duct probing that also involves temporary stent placement purely as Dilation when the stent's own placement and later removal may warrant separate consideration under insertion and removal conventions.