2025 CPT code 65091
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Eye and Ocular Adnexa Surgery Feed
Evisceration of ocular contents; without implant.
Modifiers may be applicable depending on the circumstances of the procedure. Consult the CPT manual and local payer guidelines for appropriate modifier use.Modifiers 50 (bilateral procedure) and 51 (multiple procedures) might be applicable in certain situations.
Medical necessity for evisceration is established when a patient presents with a blind, painful eye, or a severely damaged eye where vision cannot be restored, and the condition significantly impacts quality of life.The procedure aims to alleviate pain, improve cosmesis, or prevent further complications.
The ophthalmologist performs the surgical procedure under general or local anesthesia.This includes prepping and anesthetizing the patient, making the incision, excising the cornea, removing intraocular contents, closing the wound with sutures, and applying antibiotic drops. Post-operative care may be included based on payer guidelines.
In simple words: This surgery removes the inside of a diseased or damaged eye, leaving the outer white part and muscles intact.No artificial eye is put in place.
Evisceration involves the surgical removal of the intraocular contents (cornea and internal structures) of the eye while preserving the sclera (outer white layer), the extraocular muscles, and Tenon's capsule.An implant is not inserted during this procedure. The procedure typically involves an incision at the limbus, excision of the cornea, removal of intraocular contents, closure of the scleral wound with sutures, and application of antibiotic drops.Tenon's capsule and conjunctiva are closed in separate layers.
Example 1: A patient presents with a blind, painful eye due to an old injury.Evisceration without implant is performed to alleviate pain and improve cosmesis., A patient has phthisis bulbi (shrunken, atrophied eyeball) resulting in a poor cosmetic appearance.Evisceration without implant is performed to improve facial aesthetics., A patient has a severe, untreatable eye infection (e.g., endophthalmitis). Evisceration without implant is performed to remove the infected tissue and prevent further complications.
* Thorough history and physical examination documenting the indication for evisceration.* Preoperative photographs.* Operative report detailing the procedure performed, including type of incision, tissues removed, and closure technique.* Postoperative photographs and assessment of pain relief or improvement in cosmesis.* Documentation of any complications.
** The decision to perform evisceration with or without an implant depends on various factors, including the patient's specific condition, the surgeon's preference, and the availability of implants.Always refer to current coding guidelines and payer policies for the most accurate billing practices.
- Revenue Code: P4E (EYE PROCEDURE - OTHER)
- RVU: This information is not available in the provided text.RVUs vary based on geographic location and other factors. Consult your local Medicare Administrative Contractor (MAC) for specific RVU values.
- Global Days: This information is not available in the provided text.The global period for this procedure should be determined based on local payer guidelines and may vary.
- Payment Status: Active
- Modifier TC rule: The provided information does not specify whether a Technical Component (TC) modifier applies to this code. Refer to local payer guidelines.
- Fee Schedule: This information is not available in the provided text.Historical fee schedules vary by payer and location. Refer to historical payer fee schedules or other relevant databases for this information.
- Specialties:Ophthalmology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center