2025 CPT code 65105
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Eye and Ocular Adnexa Surgery Feed
Enucleation of the eye with implant and muscle attachment.
Modifiers may be applicable depending on the circumstances, such as modifier 50 for bilateral procedures or modifiers indicating the level of anesthesia provided. Consult the CPT modifier guidelines for further information.
Medical necessity for enucleation is established when the eye is severely damaged, non-salvageable, or poses a threat to the patient's health (e.g., due to malignancy, severe infection, or intractable pain).
The ophthalmologist or a qualified surgeon performs the enucleation, implant placement, and muscle attachment. Preoperative preparation and anesthesia are also part of the clinical responsibility. Postoperative care is considered separately.
In simple words: The surgeon removes a diseased or damaged eye, inserts a permanent artificial eye replacement, and attaches the eye muscles to this replacement.
Enucleation of the eye with an implant, and the extraocular muscles are attached to the implant.The procedure involves a limbal peritomy, removal of the eyeball, placement of an appropriately sized implant, attachment of the extraocular muscles to the implant, closure of Tenon's capsule and conjunctiva, and application of a pressure patch.
Example 1: A patient presents with a severely damaged eye due to trauma. The surgeon performs an enucleation with implant placement and muscle attachment to restore the eye socket's shape and function., A patient with a cancerous eye undergoes enucleation.An implant is inserted, and the extraocular muscles are attached for cosmetic purposes and to maintain eye socket integrity., A patient with a painful, non-salvageable eye due to a severe infection requires enucleation with implant and muscle attachment to resolve the infection and prevent further complications.
* Detailed history and physical examination documenting the need for enucleation.* Preoperative imaging (e.g., CT, MRI) to assess the extent of damage.* Operative report detailing the procedure performed, including the type and size of implant used.* Pathology report if applicable (e.g., biopsy of the removed eye).* Postoperative examination notes documenting the patient's recovery.
** The choice of implant material and size is determined by the surgeon based on the patient's individual needs and anatomical considerations. Postoperative care is separately reported.
- Revenue Code: P4E (EYE PROCEDURE - OTHER)
- Payment Status: Active
- Modifier TC rule: Not applicable for this procedure.
- Specialties:Ophthalmology, Ophthalmology Surgery
- Place of Service:Ambulatory Surgical Center, Inpatient Hospital, Outpatient Hospital