Benign neoplasm of unspecified lacrimal gland and duct

This code signifies the presence of a non-cancerous growth originating from either the lacrimal gland or its associated ducts, where the specific side (right or left) is not documented. These benign neoplasms are typically slow-growing and do not metastasize. Patients may present with symptoms such as a palpable mass, proptosis, or epiphora.

Utilize this code when documentation confirms a benign neoplasm of the lacrimal gland or duct, but the medical record does not specify laterality. This is appropriate for initial diagnoses, follow-up care, or surgical excision of such a lesion when the laterality is unknown or not recorded. Supporting documentation would include pathology reports confirming benignity and imaging studies or clinical notes identifying the mass without specifying the affected eye.

• Avoid using this code if laterality (right or left) is documented; instead, select the more specific D31.51 or D31.52.
• Ensure the pathology report confirms the benign nature of the neoplasm; otherwise, consider codes for malignant or uncertain behavior.
• Sequence this code as a primary diagnosis when the benign neoplasm is the reason for the encounter.