Acute dacryocystitis of unspecified lacrimal passage

This code signifies an acute inflammation of the lacrimal sac, characterized by pain, redness, and swelling in the medial canthal region, often with purulent discharge. It indicates a sudden onset and rapid progression of infection within the tear drainage system. The "unspecified lacrimal passage" denotes that the specific affected passage (e.g., right or left) is not documented.

Use this code when documentation clearly states acute dacryocystitis without specifying laterality. This typically occurs in emergency department visits or initial consultations where a definitive diagnosis of acute lacrimal sac infection is made, but the specific eye is not explicitly noted. Supporting documentation includes physician notes detailing symptoms like tenderness, erythema, and swelling over the lacrimal sac area, along with a diagnosis of acute dacryocystitis.

• Do not use this code if laterality (right or left eye) is documented; instead, select the more specific code (H04.321 or H04.322).
• Ensure the documentation specifies "acute" dacryocystitis to differentiate from chronic forms (H04.4-).
• Consider sequencing this code as the primary diagnosis if it is the main reason for the encounter.