CPT 68745 Lacrimal Fistula Reimbursement

CPT code 68745 identifies a lacrimal drainage procedure in which a surgeon constructs a fistula between the conjunctiva and the nasal cavity to relieve excessive tearing caused by complete obstruction of the punctum and canaliculi by soft tissue. This procedure is clinically important because it addresses functional vision and quality-of-life impacts from chronic epiphora and recurrent ocular surface irritation. Nationally, this code is used in ophthalmology and oculoplastic surgery settings when less invasive interventions are not feasible.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. The publication summarizes how 68745 is billed across typical surgical sites, presents common clinical indications, and highlights where documentation and coding specificity are important for claims processing.

Readers will learn the clinical context for use of CPT code 68745, typical sites of service, and the types of clinical documentation that support medical necessity. The report also outlines common modifiers associated with surgical billing and identifies where data is not available in the input. Data not available in the input includes payer-specific reimbursement rates, associated ICD-10 diagnosis codes, and related or follow-up procedure codes.

Billing Code Overview

CPT code 68745 describes a surgical procedure in which the provider creates a fistula (a drainage tract) between the conjunctiva and the nose. The procedure is performed to treat epiphora (excessive tearing) caused by complete obstruction of the punctum and canaliculi by a fleshy growth in the medial canthal area of the eye.

Service type: Ophthalmic surgical procedure, lacrimal drainage reconstruction

Typical site of service: Hospital outpatient department or ambulatory surgical center (eye/orbit surgical suite)

Clinical Context

A 68-year-old patient presents to an ophthalmology clinic with a history of chronic, profuse tearing (epiphora) of the right eye for over 12 months. Conservative measures, including topical lubrication and lacrimal probing, have failed. Examination reveals complete obstruction of the punctum and canaliculi caused by an involuted fleshy lesion at the medial canthus with recurrent conjunctival inflammation. The ophthalmic surgeon schedules a conjunctivodacryocystorhinostomy (creation of a fistula between the conjunctiva and the nasal cavity) under monitored anesthesia care. The service typically occurs in an ambulatory surgical center or hospital outpatient department. Preoperative documentation includes history and physical, informed consent, focused ocular exam, and imaging or irrigation results confirming obstruction. Intraoperative notes document the creation of the conjunctiva-to-nasal fistula, any use of grafts or stents, hemostasis, and immediate postoperative patency testing. Postoperative workflow includes recovery room monitoring, discharge instructions for ocular hygiene, and scheduled follow-up for stent removal and functional assessment of tear drainage.

Coding Specifications

Modifier	Description	When to Use
`00`	No modifier (default)	Use when no special circumstances apply.
`11`

Taxonomy Code	Specialty	Notes
207Y00000X	Ophthalmology	Primary specialty performing lacrimal surgery and conjunctivodacryocystorhinostomy.
207YA0000X	Oculoplastic Surgery	Subspecialty focused on eyelid, lacrimal and orbital procedures; commonly performs this surgery.
207L00000X	Otolaryngology (ENT)	May assist for nasal cavity exposure or if concurrent intranasal procedures are required.
208800000X	Plastic and Reconstructive Surgery	Occasionally involved for complex reconstructive needs of medial canthal defects.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`H04.53`	Obstruction of lacrimal canaliculi, bilateral	Canalicular obstruction is a direct indication for creation of an alternative tear drainage fistula when severe.
`H04.54`	Obstruction of lacrimal canaliculi, unilateral	Unilateral canalicular obstruction commonly leads to epiphora and may require conjunctivorhinostomy.
`H04.521`	Stenosis of lacrimal canaliculi, right	Stenosis causing symptomatic tearing may necessitate fistula creation when conservative measures fail.
`H04.529`	Stenosis of lacrimal canaliculi, unspecified	Used when laterality not specified but clinical need for drainage bypass exists.
`H11.001`	Conjunctival hemorrhage, unspecified eye	Concomitant conjunctival pathology or inflammation can be present; documented to guide management.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`67601`	Repair of canaliculus, simple repair	Performed when canalicular reconstruction is required before or with fistula creation.
`67800`	Incision and removal of lacrimal sac or obstruction (external dacryocystorhinostomy)	Alternative or adjunct procedure to create drainage from lacrimal sac to nasal cavity; may be performed when anatomy favors external approach.
`68760`	Excision of lesion of eyelid or periocular area, complicated	Used when the fleshy growth causing obstruction requires excision at the time of lacrimal surgery.
`31237`	Nasal/sinus endoscopy, surgical with dilation or opening of maxillary/ethmoid or frontal (flexible)	Performed by ENT for endoscopic intranasal access during conjunctivorhinostomy or to manage intranasal anatomy.
`A9270`	Non-covered item/service (example: specific stent supply)	Supplies such as specialized lacrimal stents may be reported separately per payer rules.

OpenPayer

Summary & Overview

CPT 68745: Lacrimal Fistula Creation Between Conjunctiva and Nose