Phlegmonous dacryocystitis of unspecified lacrimal passage

This code signifies an acute, severe inflammation and infection of the lacrimal sac, characterized by pus formation and tissue swelling (phlegmon). It indicates a bacterial infection affecting the tear drainage system, specifically the lacrimal sac, without specifying which eye is affected.

Use this code when documentation clearly states "phlegmonous dacryocystitis" and the laterality (right or left eye) is not specified. This typically occurs in emergency department visits or initial consultations where the specific eye has not yet been definitively documented. Supporting documentation would include physician notes detailing the signs and symptoms of acute infection, such as pain, redness, swelling, and purulent discharge in the lacrimal sac area.

• Always attempt to clarify laterality with the provider if not specified, as more specific codes exist (H04.311 for right, H04.312 for left).
• Do not confuse with chronic dacryocystitis (H04.4x) or other inflammatory conditions of the lacrimal system.
• Consider sequencing this code with an external cause code if the infection resulted from trauma, though this is less common for dacryocystitis.