CPT 68520 Lacrimal Sac Excision Reimbursement

CPT code 68520 represents surgical removal of the lacrimal sac to treat dacryocystitis, addressing chronic or recurrent inflammation of the tear drainage system. This procedure is clinically significant because it provides definitive management when conservative measures or less invasive lacrimal procedures fail, impacting surgical workflow, specialty practice patterns, and hospital and ambulatory surgical center utilization nationally. Payers commonly involved in coverage and reimbursement for this service include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.

This publication explains the clinical context of CPT code 68520, outlines typical sites of service, and summarizes what stakeholders can expect from the analysis: national benchmarks for utilization and setting of care, relevant coding considerations, and policy or coverage themes affecting surgical ophthalmology services. Readers will gain an understanding of where 68520 fits within oculoplastic surgical care, payer coverage landscape, and the operational settings in which the procedure is delivered. Data not available in the input will be noted where applicable.

Billing Code Overview

CPT code 68520 describes the surgical removal of the lacrimal sac (tear duct) performed to treat dacryocystitis, an inflammation or infection of the tear drainage system. The service type is a surgical excision of lacrimal apparatus tissue.

The typical site of service for this procedure is an operating room or ambulatory surgical center where ophthalmic or oculoplastic surgeries are performed. The procedure is performed by ophthalmologists or oculoplastic surgeons and is intended to resolve chronic or recurrent dacryocystitis when other interventions are ineffective.

Clinical Context

A typical patient is an adult presenting with chronic or recurrent dacryocystitis characterized by persistent tearing (epiphora), recurrent periorbital cellulitis, purulent discharge from the medial canthus, and a history of failed conservative therapy (topical/systemic antibiotics, lacrimal massage) or failed dacryocystorhinostomy. Preoperative evaluation includes ophthalmology or oculoplastic consultation, lacrimal system probing and irrigation to confirm obstruction and infection control, medical clearance, informed consent, and planning for anesthesia (general or monitored anesthesia care). The clinical workflow: initial outpatient evaluation and imaging if indicated (dacryocystography or CT for complex anatomy), preoperative clearance and infection control, scheduling in an ambulatory surgery center or hospital operating room, administration of anesthesia, surgical removal of the lacrimal sac (68520) with hemostasis and possible adjunct procedures, postoperative observation for bleeding, ocular pressure checks, discharge with antibiotics and wound care instructions, and outpatient follow-up for wound healing and lacrimal drainage status.

Coding Specifications

Modifier	Description	When to Use
`22`	Increased procedural services	Use when the operative report documents substantially greater work or complexity than typical for `68520`.

Taxonomy Code	Specialty	Notes
`207K00000X`	Ophthalmology	Oculoplastic surgeons and ophthalmologists commonly perform lacrimal sac surgery.
`207K00000X`	Oculoplastic Surgery (subset of ophthalmology)	Subspecialty dealing with lacrimal and periocular procedures.
`163W00000X`	Otolaryngology	ENT surgeons perform lacrimal system surgeries when combined with nasal procedures.
`2080P0207X`	Plastic and Reconstructive Surgery	Facial plastic surgeons may perform lacrimal sac procedures in complex reconstructions.
`363LE0200X`	Hospitalist/General Surgery (support)	Perioperative medical management and anesthesia coordination.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`H04.521`	Acute dacryocystitis, right lacrimal sac	Acute infection indicating need for urgent drainage or definitive surgery if recurrent.
`H04.522`	Acute dacryocystitis, left lacrimal sac	Same as above for the left side.
`H04.523`	Acute dacryocystitis, bilateral lacrimal sac	Bilateral disease potentially requiring bilateral procedures.
`H04.531`	Chronic dacryocystitis, right lacrimal sac	Chronic obstruction/infection often leading to lacrimal sac excision when other treatments fail.
`H04.532`	Chronic dacryocystitis, left lacrimal sac	Chronic disease on left side.
`H04.533`	Chronic dacryocystitis, bilateral lacrimal sac	Chronic bilateral disease indicating possible bilateral surgical management.
`H04.59`	Other disorders of lacrimal system	Used for atypical lacrimal sac pathology requiring excision.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`67830`	Dacryocystorhinostomy (DCR) with or without stent; external approach	Alternative surgical procedure to restore lacrimal drainage often performed before considering lacrimal sac excision or when creating a new lacrimal drainage pathway.
`68810`	Excision of lacrimal sac; with canaliculus reconstruction or other complex repair (note: code for canalicular procedures)	Performed when lacrimal sac excision requires concurrent canalicular repair or reconstruction.
`31025`	Excision of nasal lesion or intranasal procedure, adjunct to lacrimal surgery	ENT intranasal procedures may be performed concurrently to address nasal factors affecting lacrimal drainage.
`99140`	Emergency department on-call service (procedural assistance by another physician)	May be used in urgent settings if additional physician services are required for acute infection or complications.
`64450`	Injection, anesthetic agent; trigeminal nerve, for regional anesthesia (note: illustrative)	Regional blocks or local infiltration codes may be billed adjunctively for anesthesia support in outpatient or ambulatory settings.

OpenPayer

Summary & Overview

CPT 68520: Excision of Lacrimal Sac for Dacryocystitis