2025 CPT code 65093
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Eye and Ocular Adnexa Surgery Feed
Evisceration of ocular contents with implant placement.
Modifiers may be applicable depending on the specific circumstances of the procedure. Consult the CPT modifier guidelines for appropriate modifier usage.
Medical necessity for evisceration is established when the patient experiences significant pain and vision loss in a severely damaged or diseased eye that is unresponsive to conservative management. The procedure is deemed medically necessary to alleviate pain, prevent complications, and improve the patient's quality of life.
The ophthalmologist or qualified surgeon performs the evisceration, implant placement, and closure of the eye.This includes pre-operative assessment, surgical planning, anesthesia administration (if applicable), surgical technique, post-operative care instructions, and follow-up care.
In simple words: The surgeon removes the inside of the eye, leaving the outer white part and muscles intact.An implant is placed to maintain the eye's shape, and the eye is closed. A temporary cover may be used to support the eyelids.
Evisceration is an ophthalmic surgical procedure involving the removal of the intraocular contents (the inner structures of the eye), while preserving the sclera (the white outer layer of the eye), its attached muscles, and the surrounding orbital structures.A spherical implant is then inserted into the remaining scleral shell to maintain the eye's shape and volume. The procedure typically includes closure of the sclera with non-absorbable sutures, followed by closure of Tenon's capsule and the conjunctiva in separate layers. An orbital conformer may be placed temporarily to maintain the shape of the eyelids, and a pressure patch is applied.
Example 1: A patient presents with a severely damaged eye due to trauma, resulting in pain and vision loss. Evisceration with implant placement is performed to alleviate pain and maintain orbital volume., A patient with endophthalmitis (severe eye infection) unresponsive to medical management requires evisceration to remove infected tissue and prevent further complications. An implant is inserted to restore orbital volume., A patient with a blind, painful eye opts for evisceration with implant placement as a means of improving their comfort and cosmesis. A custom-made prosthetic eye is fitted after the healing process.
* Thorough history and physical examination documenting the indication for evisceration.* Pre-operative imaging (e.g., ultrasound, CT scan) to assess the extent of damage and intraocular pathology.* Operative report detailing the surgical procedure, including type of implant used.* Post-operative examination notes documenting the healing process and any complications.* Pathology report (if applicable) confirming the diagnosis.
** Evisceration is generally less invasive than enucleation (complete eye removal). However, enucleation is often preferred in cases of malignancy or severe trauma.The choice between evisceration and enucleation depends on individual patient circumstances and surgeon preference.Always consult with ophthalmology specialists and relevant coding guidelines for accurate coding.
- Revenue Code: P4E (EYE PROCEDURE - OTHER)
- Payment Status: Active
- Modifier TC rule: The application of a Technical Component (TC) modifier is not typically applicable to this code because it's a complete surgical procedure.
- Specialties:Ophthalmology
- Place of Service:Ambulatory Surgical Center, Inpatient Hospital, Outpatient Hospital