Summary & Overview
CPT 68440: Snip Incision of Lacrimal Punctum
CPT code 68440 represents a minor ophthalmic surgical procedure: a snip incision of the lacrimal punctum to improve tear drainage. This code is relevant nationally because it documents a common, low-complexity lacrimal intervention performed across outpatient settings and influences billing, coverage determinations, and site-of-service payment differentials. Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
Readers will learn the clinical context of the procedure, typical sites of service, and how the code is used in practice. The publication summarizes coverage considerations and benchmarking topics relevant to payers named above, highlights potential policy updates affecting outpatient ophthalmic procedure reimbursement, and outlines administrative issues that can impact claims processing for minor lacrimal procedures. The report provides actionable billing context and clarity on where this service is typically delivered, without offering clinical recommendations.
Billing Code Overview
CPT code 68440 describes a snip incision of the lacrimal punctum, a small surgical opening made in the lacrimal punctum to restore or improve tear drainage from the conjunctival sac into the lacrimal duct. This procedure is typically performed by an ophthalmologist or oculoplastic surgeon as a minor lacrimal surgery.
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Service type: Minor ophthalmic surgical procedure
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Typical site of service: Office procedure room, ambulatory surgical center, or hospital outpatient department
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Clinical & Coding Specifications
Clinical Context
A 45-year-old patient presents to an ophthalmology clinic with persistent epiphora (excess tearing) and symptomatic stenosis of the lower lacrimal punctum following chronic inflammation and recurrent conjunctivitis. After examination with slit-lamp and dye disappearance testing, the ophthalmologist confirms a narrowed punctal opening causing poor tear drainage. The provider explains the planned minor in-office procedure: a snip incision of the lacrimal punctum to enlarge the punctal orifice and restore tear outflow. Local topical anesthesia (proparacaine) and a small-gauge punctal dilator are used for initial dilation, followed by a targeted vertical snip incision with fine scissors to remove a constricting tissue lip. Hemostasis is achieved with gentle pressure; antibiotic ointment is applied. The patient is observed briefly and discharged with post-procedure instructions and a short course of topical antibiotic-steroid ointment if indicated. Typical documentation includes indication, informed consent, anesthesia, laterality, description of technique, estimated blood loss (minimal), and aftercare instructions.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
LT | Left side | When procedure performed on the left punctum |
RT |