Nasolacrimal is an adjective describing the anatomical and functional relationship between the nose and the lacrimal apparatus — the tear-producing and tear-draining structures of the eye. In clinical usage, it refers primarily to the nasolacrimal duct (ductus nasolacrimalis): the membranous channel approximately 12-15 mm in length that runs within the nasolacrimal canal (formed by the maxilla, lacrimal bone, and inferior nasal concha) and carries lacrimal fluid from the lacrimal sac to the inferior nasal meatus of the nasal cavity. The complete nasolacrimal drainage system begins at the lacrimal puncta — the tiny openings at the medial margins of the upper and lower eyelids — flows through the lacrimal canaliculi into the lacrimal sac, and exits through the nasolacrimal duct into the nose (explaining why crying causes nasal congestion). Obstruction at any point in this system causes epiphora (abnormal overflow of tears onto the face) — the most common presenting complaint of nasolacrimal disorders. In newborns, failure of the valve of Hasner (the mucosal fold at the distal duct opening) to open at birth causes neonatal nasolacrimal duct obstruction (NLDO), the most common lacrimal disorder in infancy. For AAPC-certified inpatient and outpatient ophthalmology profee coders, nasolacrimal coding requires precise documentation of the anatomical site within the drainage system (punctum vs. canaliculus vs. lacrimal sac vs. duct), laterality, acuity (neonatal/congenital vs. acquired), and procedure type — as each combination maps to a distinct billable ICD-10-CM code and CPT code with different reimbursement levels and LCD requirements.
Latin lacrima (archaic dacrima; also spelled lachryma) — “a tear (of the eye)“
The root of the entire lacrimal apparatus vocabulary; cognate with Greek dákryon (“tear”), which gives the clinical synonym prefix dacryo- used in dacryocystitis, dacryoadenitis, dacryostenosis
Standard adjectival suffix; forms adjectives from Latin nouns
The Latin word lacrima is one of the oldest recorded anatomical terms, appearing in Virgil, Cicero, and early Roman medical writers for the tears of the eye. Its Greek cognate dákryon (δάκρυον) was the preferred term in ancient Greek medicine, which is why so much clinical lacrimal terminology uses the dacryo- prefix rather than lacrimo- — both dacryocystitis (lacrimal sac inflammation) and dacryostenosis (lacrimal duct narrowing) derive from the Greek root. The Latin lacrima itself may derive from an Etruscan borrowing or from the PIE root *dakru- shared with Greek. The compound adjective nasolacrimal entered anatomical Latin nomenclature in the 16th-17th century as Renaissance anatomists formally described the tear drainage pathway — most notably Niels Stensen (Steno) in 1662, whose work on glandular anatomy clarified the lacrimal system. The informal English term tear duct is widely used by patients but is anatomically imprecise — it refers to the entire drainage system, not just the nasolacrimal duct proper — and should not be relied upon as documentation sufficient for code specificity.
🔀 ALIASES / ALTERNATE TERMS
Term
Relationship
Tear duct
Lay/patient-facing term; imprecise — encompasses entire drainage system; not sufficient for coding specificity
NLD
Clinical abbreviation for nasolacrimal duct; standard in ophthalmology documentation
Ductus nasolacrimalis
Latin anatomical term; official Terminologia Anatomica name
Nasolacrimal duct obstruction (NLDO)
Most common clinical diagnosis; neonatal vs. acquired distinction mandatory for ICD-10-CM
Neonatal NLDO
Failure of valve of Hasner to open at birth; congenital; coded H04.531-H04.539; resolves spontaneously in ~90% by 12 months
Dacryostenosis
Narrowing of the lacrimal duct; interchangeable with NLD stenosis/obstruction; no separate ICD-10 code — maps to H04.53x (neonatal) or H04.55x (acquired)
Dacryocystitis
Infection/inflammation of the lacrimal sac — a consequence of duct obstruction; coded separately H04.301-H04.309 (acute) or H04.411-H04.419 (chronic)
Epiphora
Overflow of tears onto the face — the primary symptom of NLD obstruction; coded H04.201-H04.209 when no more specific diagnosis documented
Dacryoadenitis
Inflammation of the lacrimal gland (NOT the duct/sac); coded H04.0x family; distinct from dacryocystitis
Greek root dákryon used in dacryocystitis, dacryoadenitis, dacryoliths — clinically equivalent but with Greek vs. Latin etymology split
🔗 RELATED TERMS
Lacrimal punctum (plural: puncta) — the tiny openings at the medial lid margins (upper and lower) where tears enter the drainage system; closure coded CPT 68761; obstruction or stenosis coded H04.541-H04.549
Lacrimal canaliculus (plural: canaliculi) — narrow channels (approximately 10 mm) connecting the puncta to the lacrimal sac; probing coded CPT 68840; laceration coded separately
Lacrimal sac — dilated upper portion of the nasolacrimal duct, sitting in the lacrimal groove of the lacrimal bone; primary site of dacryocystitis; surgically accessed in dacryocystorhinostomy (DCR)
Valve of Hasner (plica lacrimalis) — mucosal fold at the distal opening of the nasolacrimal duct into the inferior meatus; failure to open = neonatal NLDO; the target of nasolacrimal duct probing
Epiphora — tear overflow; the universal symptom of nasolacrimal obstruction; coded H04.201-H04.209; a symptom code — code the underlying cause (NLD obstruction) when diagnosed
Dacryocystitis — bacterial infection of the lacrimal sac (most commonly S. aureus, Streptococcus); presents with medial canthal swelling, pain, and purulent discharge; acute = H04.301-H04.309; chronic = H04.411-H04.419; can cause lacrimal sac abscess requiring I&D
Dacryocystorhinostomy (DCR) — gold-standard surgical treatment creating a new opening from the lacrimal sac directly into the nasal cavity, bypassing the obstructed duct; external vs. endoscopic approach; CPT 68720 (external); endonasal/endoscopic uses 68720 or unlisted CPT 68899 depending on payer
Nasolacrimal duct probing — first-line intervention for neonatal NLDO after conservative measures fail; CPT 68810 (without anesthesia) / 68811 (under general anesthesia); age and anesthesia type drive code selection
Silicone intubation / stenting — placement of silicone tube through nasolacrimal system to maintain patency after probing; CPT 68815; NOTE: silicone stenting alone may not be covered by all payers — verify LCD
Balloon catheter dilation — transluminal balloon dilation of NLD; CPT 68816; covered by Medicare under LCD L34171 for specific indications
Dacryolith — calcified concretion within the lacrimal sac or duct; coded H04.511-H04.519; may require surgical removal
Lacrimal gland — the secretory gland producing lacrimal fluid (superolateral orbit); distinct from the drainage system — gland disorders (dacryoadenitis, dry eye) use different code families
Inferior nasal meatus — nasal opening where the nasolacrimal duct terminates; relevant in endoscopic DCR approach for anatomical visualization
Facial nerve (CN VII) — carries parasympathetic secretomotor fibers to the lacrimal gland; CN VII palsy causes dry eye (reduced tear production), not nasolacrimal obstruction
CODING CORNER
📋 ICD-10-CM — Nasolacrimal / Lacrimal System Disorders
⚠️ Laterality is required for all H04 codes — parent codes H04.20, H04.30, H04.41, H04.53, H04.54, H04.55 are NOT billable without the laterality character. 1 = right, 2 = left, 3 = bilateral, 9 = unspecified. Congenital NLD obstruction = H04.53x; Acquired NLD stenosis = H04.55x — do NOT use Q10.5 (congenital stenosis) interchangeably with H04.53x for neonatal NLDO; Q10.5 describes a true structural congenital anomaly, while H04.53x is neonatal/developmental failure of canalization. Epiphora (H04.20x) is a symptom code — do NOT use when a more specific diagnosis (dacryocystitis, NLDO) is documented.
Neonatal obstruction of right nasolacrimal duct (failure of valve of Hasner — most common; resolves ~90% by 12 months)
H04.532
Neonatal obstruction of left nasolacrimal duct
H04.533
Neonatal obstruction of bilateral nasolacrimal ducts
H04.539
Neonatal obstruction of unspecified nasolacrimal duct (avoid — query for laterality)
Nasolacrimal Duct Stenosis — Acquired
ICD-10-CM Code
Description
H04.551
Acquired stenosis of right nasolacrimal duct
H04.552
Acquired stenosis of left nasolacrimal duct
H04.553
Acquired stenosis of bilateral nasolacrimal ducts
H04.559
Acquired stenosis of unspecified nasolacrimal duct (avoid — query for laterality)
Lacrimal Sac Disorders
ICD-10-CM Code
Description
H04.511
Dacryolith of right lacrimal sac and duct (calcified concretion — may require surgical removal)
H04.512
Dacryolith of left lacrimal sac and duct
H04.513
Dacryolith of bilateral lacrimal sac and duct
H04.519
Dacryolith of unspecified lacrimal sac and duct
Dacryocystitis — Lacrimal Sac Infection
ICD-10-CM Code
Description
H04.301
Unspecified dacryocystitis of right lacrimal passage (acute; most common complication of NLDO)
H04.302
Unspecified dacryocystitis of left lacrimal passage
H04.303
Unspecified dacryocystitis of bilateral lacrimal passages
H04.309
Unspecified dacryocystitis of unspecified lacrimal passage
H04.311
Phlegmonous dacryocystitis of right lacrimal passage (acute purulent — abscess formation; may require I&D)
H04.312
Phlegmonous dacryocystitis of left lacrimal passage
H04.411
Chronic dacryocystitis of right lacrimal passage
H04.412
Chronic dacryocystitis of left lacrimal passage
H04.413
Chronic dacryocystitis of bilateral lacrimal passages
Lacrimal Punctum & Canaliculus Stenosis
ICD-10-CM Code
Description
H04.541
Stenosis of right lacrimal canaliculi
H04.542
Stenosis of left lacrimal canaliculi
H04.543
Stenosis of bilateral lacrimal canaliculi
H04.549
Stenosis of unspecified lacrimal canaliculi
Epiphora — Symptom Code (Use Only When No Specific Diagnosis)
ICD-10-CM Code
Description
H04.201
Unspecified epiphora, right lacrimal gland (tear overflow — symptom code only; do NOT use when NLD obstruction/dacryocystitis diagnosed)
H04.202
Unspecified epiphora, left lacrimal gland
H04.203
Unspecified epiphora, bilateral lacrimal glands
Congenital Lacrimal Anomalies (Structural — Distinct from Neonatal NLDO)
ICD-10-CM Code
Description
Q10.4
Absence and agenesis of lacrimal apparatus (structural absence — not neonatal NLDO; excluded from H04 family)
Q10.5
Congenital stenosis and stricture of lacrimal duct (true structural stenosis; distinguish from neonatal NLDO H04.53x)
Q10.6
Other congenital malformations of lacrimal apparatus
🔧 CPT Codes — Nasolacrimal System Procedures
⚠️ CPT 68810 (probing without general anesthesia) and 68811 (probing with general anesthesia) are DISTINCT codes — anesthesia type is the differentiator. 68810 is typically performed in-office on infants when conservative treatment has failed; 68811 requires separate anesthesia documentation. Do NOT bill 68801 (punctum dilation) AND 68810 (duct probing) on the same eye same date — 68801 is bundled into 68810 per NCCI when performed on the same side. Medicare LCD L34171 governs coverage criteria for 68801, 68810, 68815, and 68816.
Dilation & Probing
CPT Code
Description
68801
Dilation of lacrimal punctum, with or without irrigation (punctum dilation alone — office procedure; NOT billable same side same date as 68810 per NCCI)
68810
Probing of nasolacrimal duct, with or without irrigation (without general anesthesia — standard first-line procedure for neonatal NLDO; typically 6-12 months of age)
68811
Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia (older child or complex case; separate anesthesia documentation required)
68840
Probing of lacrimal canaliculi, with or without irrigation (canaliculus probing — distinct from NLD probing; different anatomical site)
Intubation, Stenting & Balloon Dilation
CPT Code
Description
68815
Probing of nasolacrimal duct, with or without irrigation; with insertion of tube or stent (silicone intubation — NOTE: silicone stenting alone may not be covered per LCD; verify payer policy before billing)
68816
Probing of nasolacrimal duct, with or without irrigation; with transluminal balloon catheter dilation (balloon dacryoplasty — covered by Medicare under LCD L34171 for specific recurrent NLDO cases)
Dacryocystorhinostomy (DCR) — Surgical Bypass
CPT Code
Description
68720
Dacryocystorhinostomy(fistulization of lacrimal sac to nasal cavity — gold standard for recurrent/adult NLD obstruction; external approach; endoscopic/endonasal approach also reported with 68720 or 68899 depending on payer)
68745
Conjunctivorhinostomy; without tube (fistulization of conjunctiva to nasal cavity — for complete canalicular obstruction where sac-to-nose bypass insufficient)
68750
Conjunctivorhinostomy; with insertion of tube or stent (Jones tube placement — permanent glass tube bypassing entire lacrimal drainage system)
Lacrimal Punctum Closure & Other
CPT Code
Description
68761
Closure of lacrimal punctum; by thermocauterization, ligation, or laser surgery, each (punctal occlusion for dry eye — billed per punctum; typically 4 puncta total; commonly paired with H04.12x dry eye codes)
68899
Unlisted procedure, lacrimal system (use for endonasal endoscopic DCR when payer does not accept 68720 for endoscopic approach; requires special report)
Level IV surgical pathology (lacrimal sac specimen sent to pathology — required when DCR biopsy specimen obtained to rule out lacrimal sac tumor or granulomatous disease; always pair with 68720)
Right side — append to all unilateral nasolacrimal procedures; required per Medicare and most commercial payers for 68801, 68810, 68811, 68815, 68816, 68720
Bilateral — bilateral NLD probing or DCR at same session; confirm payer accepts vs. separate -RT/-LT lines (most payers prefer separate lines for lacrimal codes)
Distinct procedural service — e.g., 68840 (canaliculus probing) distinct from 68810 (NLD probing) same session different anatomical site; or 88305 pathology distinct from surgical 68720
Staged procedure — planned second-stage DCR (68720) following initial failed probing (68810/68811) when documented as planned sequence
⚠️ Coding Notes & Payer Guidance
68801 is bundled into 68810 per NCCI — same side, same date: CPT 68801 (punctum dilation) is included in the procedural description of 68810 (NLD probing) when performed on the same eye at the same session. Billing both on the same date for the same laterality will deny as a NCCI bundle. Modifier -59 does NOT overcome this edit because punctum dilation is considered an inherent component of duct probing. Only bill 68801 separately when performed on the opposite eye, or at a completely separate encounter.
H04.531-H04.539 (neonatal) vs. H04.551-H04.559 (acquired) — age is the differentiator: Neonatal NLD obstruction (H04.531) is the appropriate code for infants presenting with epiphora from birth or early infancy due to failure of canalization. Once the patient is past the neonatal/developmental period and obstruction develops from a different cause (scarring, surgery, trauma, chronic infection), the acquired stenosis codes (H04.551) apply. Using H04.531 in a non-neonatal patient — as one AAPC forum case noted — generates payer denials citing age inconsistency.
LCD L34171 — coverage criteria for 68810, 68815, and 68816: Medicare’s LCD for nasolacrimal duct probing requires documentation of: (1) persistent epiphora or recurrent dacryocystitis despite conservative management (massage, topical antibiotics); (2) age ≥6 months for initial probing; (3) for balloon dilation (68816), failed prior probing. Probing before 6 months of age is typically not covered unless complicated by dacryocystitis or abscess. Ensure these criteria are documented in the record before billing.
Endoscopic DCR and CPT 68720: The external approach DCR (68720) has been used to report endonasal endoscopic DCR by many payers, as there is no dedicated endoscopic DCR CPT code. However, some payers require 68899 (unlisted) for the endoscopic approach with a special report. Verify payer policy before defaulting to 68720 for endoscopic cases — a special report documenting the endoscopic approach, operative time, and equipment used is good practice regardless.
Epiphora (H04.20x) is a symptom code — do not use when diagnosis is confirmed: When a provider has documented NLD obstruction or dacryocystitis, the appropriate specific code (H04.531, H04.551, H04.301, etc.) must be used — not the epiphora symptom code. H04.20x is reserved for tear overflow that has not yet been attributed to a specific underlying cause. Using the symptom code when the diagnosis is documented = undercoding and inaccurate coding.
Lacrimal sac tumor — do not miss 88305: When DCR (68720) is performed and a biopsy of the lacrimal sac wall is obtained (standard practice to rule out lacrimal sac mucocele, papilloma, or carcinoma), 88305 (Level IV surgical pathology) should be reported for the pathology interpretation. It is a separately billable service from the surgical CPT and is consistently omitted as a missed charge in ophthalmology profee billing.
Crystal's Coder Hub