Phlegmonous dacryocystitis of bilateral lacrimal passages

This code signifies a severe, purulent inflammation of the tear sac (dacryocystitis) affecting both eyes. The term "phlegmonous" indicates a diffuse, spreading inflammation with pus formation, often involving the surrounding tissues. This condition typically presents with significant pain, swelling, redness, and tenderness over the lacrimal sac area bilaterally.

Use this code when documentation clearly states a diagnosis of phlegmonous dacryocystitis impacting both the right and left lacrimal passages. Supporting documentation should describe bilateral signs of acute infection, such as erythema, edema, tenderness, and possibly purulent discharge from the puncta or fistula formation. This code is appropriate for acute, severe infections requiring medical or surgical intervention.

• Ensure documentation explicitly specifies "bilateral" involvement; otherwise, a unilateral code (H04.311 or H04.312) should be used.
• Distinguish from chronic dacryocystitis (H04.4x) or other lacrimal gland disorders (H04.xx).
• Code any associated infectious agents (e.g., B95-B97) as secondary diagnoses if identified and documented.