2025 CPT code 65101
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Eye and Ocular Adnexa Surgery Feed
Enucleation of the eye without implant.
Modifiers may be applied as clinically indicated (e.g., -22 for increased procedural services, -50 for bilateral procedures, etc.).
Medical necessity is established by documentation demonstrating the presence of a condition that necessitates enucleation (e.g., life-threatening infection, intractable pain, severe trauma, malignancy).The procedure must be medically appropriate and necessary to alleviate the patient's symptoms or prevent further complications.
The ophthalmologist or oculoplastic surgeon is responsible for performing the enucleation, including pre-operative assessment, surgical technique, post-operative care and follow-up.
In simple words: This surgery removes the entire eyeball, but leaves the muscles and other tissues around the eye in place. It's usually done for serious eye problems like severe injuries, cancer, or infections that can't be treated any other way.A temporary implant may be used to help the eye socket heal properly before a permanent artificial eye is fitted.
Enucleation is the surgical removal of the entire eyeball, leaving the eye muscles and surrounding orbital contents intact.The procedure is typically performed to address conditions such as severe eye injuries, tumors, or infections that are unresponsive to less invasive treatments.An orbital conformer may be temporarily placed to maintain eyelid shape until a permanent prosthesis is fitted. No ocular implant is inserted during this procedure.
Example 1: A patient presents with a large, rapidly growing intraocular melanoma. Enucleation is performed to remove the tumor and prevent its spread.A temporary conformer is placed., A patient suffers a severe eye injury resulting in irreparable damage and intractable pain. Enucleation is performed to alleviate pain and prevent further complications. A temporary conformer is used, and the patient is referred to an ocularist., A patient with a history of chronic uveitis and severe vision loss experiences intractable pain and inflammation despite maximal medical management. Enucleation is performed to alleviate the patient's symptoms.A temporary conformer is used, along with post-operative antibiotics and anti-inflammatory drops.The patient is referred to an ocularist for a prosthesis.
Detailed medical history including the reason for enucleation (e.g., tumor, trauma, infection). Pre-operative examination findings (e.g., visual acuity, ophthalmoscopy, imaging studies). Operative report detailing the surgical technique, and any complications.Post-operative care instructions and follow-up plan. Pathology report if applicable (e.g., tumor type and size).
** This code does not include the fitting or placement of a permanent ocular prosthesis; separate codes should be used for this purpose.Always refer to the latest CPT manual and local coding guidelines for the most up-to-date information.
- Revenue Code: P4E (EYE PROCEDURE - OTHER)
- RVU: Refer to current Medicare fee schedules and local payment rates for RVU information.Reimbursement varies by location, facility type, and patient's specific Medicare plan.
- Global Days: The global period for this procedure will vary depending on the payer and any associated services.Clarify with the specific payer or refer to local coding guidelines.
- Payment Status: Active
- Modifier TC rule: Technical Component (TC) modifiers are not typically applicable to this code.
- Fee Schedule: Refer to historical Medicare fee schedules for reimbursement information.
- Specialties:Ophthalmology, Oculoplastic Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center