Lacrimal fistula bilateral lacrimal passages

This code signifies an abnormal, persistent communication between the lacrimal drainage system and the skin or conjunctiva, affecting both eyes. This condition results in continuous or intermittent discharge of tears onto the skin surface or into the conjunctival sac, bypassing the normal tear drainage pathway.

Assign this code when documentation explicitly states the presence of a lacrimal fistula affecting both the right and left lacrimal passages. This typically occurs due to congenital anomalies, trauma, infection, or surgical complications. The physician's notes should clearly indicate the bilateral nature of the fistula.

• Ensure documentation specifies "bilateral" involvement; otherwise, a unilateral code or unspecified code may be more appropriate.
• Investigate the underlying cause of the fistula (e.g., trauma, infection) for potential additional coding.
• Distinguish from epiphora (excessive tearing) without an identifiable fistula, which would be coded differently.