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BETA v.3.0

2025 CPT code 68811

Probing of nasolacrimal duct, with or without irrigation; requiring general anesthesia.

Use modifier 50 for bilateral procedures. Some payers may prefer using LT and RT. Ensure documentation supports medical necessity and clearly describes the procedure performed.

Modifiers 50, LT, RT, and others may be applicable. Modifier 50 is used for bilateral procedures. Some payers may prefer LT and RT modifiers instead of 50.

Medical necessity for 68811 must be supported by documentation of failed conservative treatments for nasolacrimal duct obstruction, such as massage and topical antibiotics, or the presence of complications like dacryocystitis. The medical record should clearly demonstrate that the procedure was necessary for the patient's health and well-being.

The physician is responsible for administering general anesthesia, dilating the lacrimal drainage system, probing the nasolacrimal duct, irrigating the duct as needed, and instilling antibiotics.

IMPORTANT:For a bilateral procedure, use modifier 50 or LT/RT depending on payer preference. If performed under local topical anesthesia, use 68810. If a tube or stent is inserted, use 68815. If balloon catheter dilation is also performed, use 68816. Do not report 68801 (dilation of lacrimal punctum) if performed on the same day and side as 68811.

In simple words: This procedure involves opening a blocked tear duct while the patient is under general anesthesia. The doctor uses a small probe to clear the blockage and may also flush the duct with a sterile solution.

With the patient under general anesthesia, the provider probes the nasolacrimal duct to identify a possible obstruction or stricture. The procedure may include irrigation of the duct. The provider dilates the lacrimal drainage system, inserting a punctual dilator to widen the punctum. A probe is then inserted into the inferior or superior punctum and advanced until resistance is met. The canaliculus is irrigated with fluorescein-stained saline, followed by additional irrigation if needed. Finally, the cannula is removed, and antibiotics are instilled.

Example 1: A pediatric patient presents with persistent tearing and discharge from one eye due to a suspected nasolacrimal duct obstruction. The physician performs probing of the nasolacrimal duct under general anesthesia to clear the blockage., An adult patient with chronic dacryocystitis undergoes probing of the nasolacrimal duct under general anesthesia after conservative treatments fail to resolve the infection., A child with congenital nasolacrimal duct obstruction requires probing of the duct under general anesthesia to establish patency and alleviate symptoms.

Documentation should include the reason for the procedure (e.g., persistent tearing, dacryocystitis), the use of general anesthesia, a description of the probing and irrigation process, and any complications encountered. The medical record should also support the medical necessity of the procedure.

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