087X7ZZ
Dilation Lacrimal Duct, Right to No Qualifier with No Device, Via Natural or Artificial Opening Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | 8 Eye |
| Operation | 7 Dilation |
| Body Part | X Lacrimal Duct, Right |
| Approach | 7 Via Natural or Artificial Opening |
| Device | Z No 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, Right
The right lacrimal duct, particularly the nasolacrimal segment descending from the lacrimal sac into the inferior meatus of the nose, is dilated to relieve obstruction that causes chronic epiphora or recurrent dacryocystitis. In infants this is commonly performed as probing of a congenitally imperforate duct, while in adults acquired stenosis from scarring, chronic inflammation, or prior surgery is treated with graduated probes or balloon dacryoplasty, sometimes followed by temporary stent placement to maintain patency. Because the duct runs through a narrow bony canal, dilation carries a risk of false passage formation if performed too forcefully, and success can be limited by the degree and location of the stricture. Documentation should indicate that the intraluminal diameter of the existing duct was widened rather than a new passage created.
Approach: Via Natural or Artificial Opening
Via Natural or Artificial Opening means the instrument reaches the target site by passing through an existing body orifice, such as the mouth or urethra, or a surgically created opening like a stoma, without additional incision or scope guidance. It is distinguished from the Endoscopic variant by the absence of a visualizing scope, and from External by actually traversing into the body through that opening.
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.