epiphora

DEFINITION of epiphora

Epiphora is an overflow of tears onto the face — beyond normal emotional crying — caused by either overproduction of tears (hyperlacrimation) or, more commonly, impaired drainage of tears through the nasolacrimal outflow system. Under normal physiology, tears drain from the ocular surface through the upper and lower puncta → canaliculi → lacrimal sac → nasolacrimal duct → inferior nasal meatus. When any part of this pathway is obstructed, narrowed, or when the eyelid fails to maintain proper apposition to the globe (disrupting the lacrimal pump), tears overflow onto the cheek. From a medical-coding perspective, epiphora documentation must clarify: Etiology (excess lacrimation vs. insufficient drainage) Underlying cause (lid malposition, punctal stenosis, nasolacrimal duct obstruction, reflex irritation) Laterality (right, left, bilateral) Whether the condition is congenital or acquired (Excludes1 note for congenital on H04.2-) Treatment rendered (probing, irrigation, dilation, DCR, stent placement)

These distinctions affect both ICD-10-CM code specificity and CPT code selection. Epiphora has been described in Egyptian medical texts dating to 1500 BC and was noted by Hippocrates (460-370 BC) — making it one of the oldest documented clinical signs in medicine. The term derives from ancient Greek epiphora meaning “a bringing upon” or “an overflow.”

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ETYMOLOGY of epiphora

greek - The word derives from ancient Greek:

epi-: From Greek epi (ἐπί), meaning “upon,” “on,” “over,” or “in addition to” — conveying the sense of something flowing over or being brought upon the face

phor- / -phora: From Greek phérein (φέρειν), meaning “to carry,” “to bring,” or “to bear” — the same root found in metaphor (meta- + phora = a carrying across), phosphorus (phos- + phoros = light-bearing), and semaphore

• epi- → Greek epi, meaning “upon, over, on top of”
• -phora → Greek phérein, meaning “to carry, to bring”
• epiphora literally means “a bringing/carrying upon [the face]” — i.e., tears spilling over onto the cheek

Note: The same Greek word epiphora also refers to a rhetorical device (repetition of words at the end of successive phrases) — also known as epistrophe. In medicine, the term was specifically applied to lacrimal overflow as early as the Hippocratic corpus and was formalized in modern ophthalmology through Latin medical nomenclature.

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Related Terms

Term	Meaning	Coding Relevance
dacryocystitis	Infection of the lacrimal sac; causes nasolacrimal duct obstruction → epiphora	H04.0- series; common cause of epiphora in adults; code as primary diagnosis when infection is present
dacryostenosis	Stenosis/narrowing of the nasolacrimal duct	H04.55- series; most common acquired cause of epiphora in adults
punctal stenosis	Narrowing or occlusion of the lacrimal punctum	H04.56- series; causes outflow obstruction epiphora; may require punctal dilation (CPT 68700)
nasolacrimal duct obstruction (NLDO)	Blockage of the nasolacrimal duct	H04.55- series; most common cause of epiphora in infants (congenital NLDO); CPT 68810
ectropion	Outward turning of eyelid; punctum everts away from globe → impaired drainage	H02.1- series; lid repair (67917) resolves secondary epiphora; code both conditions
entropion	Inward turning of eyelid; lash irritation causes reflex hyperlacrimation	H02.0- series; lid repair resolves secondary epiphora; code both
trichiasis	Misdirected lashes contacting cornea; reflex tearing	H02.05- series; code as underlying cause of reflex epiphora
Bell’s palsy	CN VII palsy disrupts orbicularis-driven lacrimal pump	G51.0; sequence Bell’s palsy first; epiphora is a secondary manifestation
dacryocystorhinostomy (DCR)	Surgical creation of new drainage pathway from lacrimal sac to nasal cavity	CPT 68720; primary surgical treatment for nasolacrimal duct obstruction-related epiphora
conjunctivochalasis	Redundant conjunctival tissue obstructing lower punctum	H11.82- series; underdiagnosed cause of epiphora in older adults

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Common Medical Terms Using the Root

• Metaphor - A figure of speech; meta- (across) + phora (carrying) — same phérein root as epiphora

• Semaphore - A signaling system; sema- (sign) + phora (carrying) — same root

• Phosphorus - The element; phos- (light) + phoros (bearing) — same phérein root

• Dacryorrhea - Excessive flow of tears (dacryo- = tear + -rrhea = flow); clinical synonym for epiphora

• Dacryocystitis - Infection of the lacrimal sac (dacryo- = tear + cyst- = sac + -itis); leading infectious cause of epiphora

• Lacrimation - The secretion of tears; from Latin lacrima (tear); used interchangeably with tearing

• Hyperlacrimation - Excessive tear production specifically due to overactive lacrimal gland (as opposed to drainage failure)

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Common Clinical Causes by Category

Impaired Drainage — Outflow Obstruction (most common)

• Nasolacrimal duct obstruction (NLDO): Most common cause; congenital (fails to open at birth) or acquired (age-related stenosis, infection, trauma)

• Dacryocystitis: Infection of lacrimal sac causing secondary obstruction; presents with epiphora + pain/swelling at medial canthal angle

• Punctal stenosis: Narrowing of upper or lower punctum; common in elderly and after topical chemotherapy drops

• Canalicular obstruction: Scarring from herpes simplex, radiation, chemotherapy (topical or systemic), or trauma

• Eyelid malposition: Ectropion (punctum everts away from globe) or entropion (irritation causes reflex tearing + drainage impaired)

• Lacrimal pump failure: orbicularis muscle weakness from Bell’s palsy or lower lid laxity → impaired active pumping of tears into canaliculi

Excess Tear Production (Reflex/Hyperlacrimation)

• Ocular surface irritation: trichiasis, corneal abrasion, corneal ulcer, blepharitis, dry eye syndrome, conjunctivitis

• Allergic conjunctivitis; chemical/irritant exposure

• Uveitis / iritis; foreign body

• Medication side effects (prostaglandin analogs, systemic chemotherapy)

Diagnostic Workup

• Clinical exam: Lid position, punctal apposition, punctal size, Jones dye tests (primary and secondary)

• Punctal irrigation / probing: Tests patency of canaliculi and nasolacrimal duct

• Dacryoscintigraphy: Nuclear medicine imaging of lacrimal drainage; functional assessment

• Nasolacrimal duct probing (68810): Diagnostic and therapeutic in infants with congenital NLDO

• CT orbit / sinuses: For suspected bony obstruction, dacryocystocele, or post-traumatic obstruction

Treatment Overview

• Observation: Congenital NLDO in infants — most resolve spontaneously by 12 months; massage of lacrimal sac (Crigler technique)

• Probing and irrigation (68810 / 68811): First-line intervention for congenital NLDO after failed observation; also diagnostic in adults

• Punctal dilation (68700): For punctal stenosis

• Silicone tube intubation (68815 monocanalicular / 68816 bicanalicular): Stent placed to maintain patency; removed in office later

• Balloon catheter dilation (68811): Balloon dilation of nasolacrimal duct

• Dacryocystorhinostomy (DCR) (68720): Gold-standard surgical correction for acquired NLDO; creates new bony ostium from lacrimal sac to nasal cavity

• Endoscopic DCR (68720 — same CPT; approach documented in operative note): Endonasal approach; avoids external scar

• Jones tube placement (68745): Permanent Pyrex bypass tube; for canalicular obstruction where DCR alone is insufficient

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Documentation Clues for Coders

Look for phrases such as:

• “Excessive tearing / watery eye”

• “Tears overflowing onto cheek”

• “Punctal stenosis identified”

• “Nasolacrimal duct obstruction confirmed”

• “Jones dye test positive/negative”

• “Dacryocystitis present” (→ H04.0- as primary; epiphora secondary)

• “Punctal dilation and irrigation performed” (→ 68700)

• “Nasolacrimal duct probing performed” (→ 68810)

• “Silicone intubation placed” (→ 68815 or 68816)

• “DCR performed” (→ 68720)

• “Jones tube placed” (→ 68745)

• “Congenital NLDO” (→ Q10.5 — Excludes1 from H04.2-)

• “Right/left/bilateral” (required for all H04.2- codes)

These help determine etiology type, laterality, congenital vs. acquired, and the appropriate CPT procedural code.

Coder’s Notes

• H04.2- has a critical subcategory split: H04.21- = epiphora due to excess lacrimation (overproduction); H04.22- = epiphora due to insufficient drainage (outflow problem); do NOT default to H04.20- (unspecified) when documentation specifies the mechanism — specificity is required for accuracy

• Laterality is required for all H04.2- codes — 1 = right, 2 = left, 3 = bilateral, 9 = unspecified; always capture the side from the documentation

• Critical Excludes1: Congenital malformations of lacrimal system (Q10.4-Q10.6) are Excludes1 from H04.-; for congenital NLDO, use Q10.5 (congenital stenosis and stricture of lacrimal duct) — NOT H04.2-

• Epiphora is frequently a secondary/manifestation code: When the underlying cause is documented (ectropion, NLDO, dacryocystitis, Bell’s palsy), code the primary cause first and epiphora additionally — it supports medical necessity for both lid repair and lacrimal procedures

• 68810 vs. 68811: 68810 = probing with or without irrigation; 68811 = probing plus balloon catheter dilation — do NOT use 68810 when a balloon is placed; that’s an upgrade to 68811

• 68815 vs. 68816: 68815 = probing with insertion of tube or stent (monocanalicular or bicanalicular in one pass); 68816 = bicanalicular intubation with nasal catheter; verify the operative report carefully — the exact stent type and placement route determines the correct code

• 68720 DCR carries a 90-day global period — do NOT separately bill post-op visits during the global period without modifier -24 (unrelated E/M) or -79 (unrelated procedure)

• Modifier -50: For bilateral procedures (bilateral probing, bilateral DCR) — check payer policy vs. two-line billing with -LT / -RT

• Modifier -RT / -LT: Required by many payers for unilateral lacrimal procedures in lieu of or in addition to diagnosis laterality; always append for unilateral claims

• Modifier -25: When a significant separately identifiable E/M service is performed on the same day as punctal dilation or nasolacrimal probing in an office setting

• Pediatric anesthesia: Lacrimal probing in infants is typically performed under general anesthesia — anesthesia code 00140 (anesthesia for procedures on eye) applies; document patient age for anesthesia base unit calculation

ICD-10-CM Diagnosis Codes

Code	Description
H04.201	Unspecified epiphora, right side (use only when mechanism not documented)
H04.202	Unspecified epiphora, left side
H04.203	Unspecified epiphora, bilateral
H04.209	Unspecified epiphora, unspecified side (avoid when laterality is documented)
H04.211	Epiphora due to excess lacrimation, right side (overproduction — reflex, irritation-based)
H04.212	Epiphora due to excess lacrimation, left side
H04.213	Epiphora due to excess lacrimation, bilateral
H04.221	Epiphora due to insufficient drainage, right side (outflow obstruction — punctal stenosis, NLDO, lid malposition)
H04.222	Epiphora due to insufficient drainage, left side
H04.223	Epiphora due to insufficient drainage, bilateral
H04.001	Unspecified dacryoadenitis, right lacrimal gland (if lacrimal gland cause)
H04.411	Chronic dacryocystitis, right lacrimal passage (dacryocystitis → epiphora; sequence first)
H04.412	Chronic dacryocystitis, left lacrimal passage
H04.551	Acquired stenosis of right nasolacrimal duct (primary cause of outflow epiphora in adults)
H04.552	Acquired stenosis of left nasolacrimal duct
H04.561	Stenosis of right lacrimal punctum (punctal stenosis — primary outflow cause)
H04.562	Stenosis of left lacrimal punctum
Q10.5	Congenital stenosis and stricture of lacrimal duct — congenital NLDO; Excludes1 from H04.-
H11.821	Conjunctivochalasis, right eye (underdiagnosed cause of epiphora in elderly)
H11.822	Conjunctivochalasis, left eye

CPT Codes — Lacrimal System Procedures

Code	Description
68700	Plastic repair of canaliculi (punctal dilation / repair for punctal stenosis)
68705	Correction of everted punctum, cautery
68720	Dacryocystorhinostomy (DCR) — fistulization of lacrimal sac to nasal cavity; gold-standard for NLDO
68745	Conjunctivorhinostomy; with insertion of Jones tube (for canalicular obstruction)
68810	Probing of nasolacrimal duct, with or without irrigation (diagnostic and therapeutic)
68811	Probing of nasolacrimal duct, with balloon catheter dilation
68815	Probing of nasolacrimal duct with insertion of tube or stent (monocanalicular or standard intubation)
68816	Probing of nasolacrimal duct with bicanalicular intubation, with nasal catheter
68840	Probing of lacrimal canaliculi, with or without irrigation (canalicular — NOT nasolacrimal duct)

Common Modifiers

Modifier	Use
-LT	Left side — append to lacrimal procedure CPT codes for unilateral left-sided procedures
-RT	Right side — append to lacrimal procedure CPT codes for unilateral right-sided procedures
-50	Bilateral procedure — bilateral probing or DCR same session (check payer vs. two-line -LT/-RT preference)
-25	Significant, separately identifiable E/M service same day as punctal dilation or probing
-24	Unrelated E/M service during DCR postoperative global period
-79	Unrelated procedure during DCR postoperative period
-58	Staged procedure — planned second-stage lacrimal surgery during global period (e.g., stent removal after DCR)
-52	Reduced services — incomplete probing or DCR
-22	Increased procedural services — complex DCR (prior failed surgery, scarring, bony obstruction, atypical anatomy)

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DERIVATIONS of epiphora

TABLE definition AS Definition
FROM #medterm 
WHERE length(filter(roots, (word) => econtains([[epiphora]].roots, word))) > 0 AND file.name != [[epiphora]].file.name
SORT file.name ASC

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Query functionality

TABLE definition AS Definition
FROM #medterm 
WHERE length(filter(definition, (word) => econtains([[epiphora]].definition, word))) > 0 AND file.name != [[epiphora]].file.name

Med roots Appendix A Prefixes Appendix B Combining Forms Appendix C Suffixes Appendix D Suffix forms