2025 CPT code 65103
(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 an implant; muscles not attached to the implant.
Modifiers may be applicable depending on the circumstances of the procedure. For example, modifier 50 might be used for bilateral procedures (if the surgeon simultaneously or subsequently performs enucleation on the other eye). Modifier 22 can be used for increased procedural services. Check with your payer for their requirements.
Medical necessity for enucleation is typically established by the presence of a painful, blind, or cancerous eye.Severe trauma, infection, or other conditions threatening the health of the eye or surrounding tissues also justify the procedure.Documentation must support the medical indication for surgery and the chosen surgical approach.
The ophthalmologist or oculoplastic surgeon is responsible for pre-operative assessment, performing the enucleation, implanting the prosthesis, and post-operative care.
In simple words: The surgeon removes the entire eye, leaving the muscles that move the eye intact.An artificial eye implant is placed in the socket to fill the space, but the muscles are not attached to the implant.
This procedure involves the complete removal of the eyeball (enucleation), including its contents, while preserving the extraocular muscles.A spherical implant is inserted into the empty socket to maintain the shape and volume of the eye.Crucially, in this specific code, the extraocular muscles are not attached to the implant.
Example 1: A patient presents with a painful blind eye due to severe trauma. Enucleation with implant (muscles not attached) is performed to alleviate pain and improve cosmesis., A patient is diagnosed with intraocular melanoma that cannot be treated with other methods. Enucleation with implant is performed to remove the cancerous tissue and restore orbital volume., A patient experiences severe, intractable pain from a blind eye due to an infection.Enucleation with implant is elected to eliminate the source of pain and enhance appearance.
Detailed history and physical examination, including visual acuity assessment.Preoperative imaging (e.g., CT scan or MRI) to assess the extent of disease and plan the surgery. Intraoperative findings and surgical notes detailing the type of implant used and the technique employed. Postoperative examination findings and any complications.
** The choice of implant material (e.g., plastic or hydroxyapatite) is at the surgeon's discretion and should be documented. The use of a surgical assistant may be billable depending on payer rules and medical necessity, usually with modifier 80 (Assistant surgeon) or potentially modifier AS if applicable.Post-operative care may include fitting a prosthetic eye at a later date.
- Revenue Code: P4E (EYE PROCEDURE - OTHER)
- RVU: This information is not available in the provided source.Consult the current Medicare Physician Fee Schedule for RVU values and payment rates.
- Global Days : The global period for this procedure is not specified in the source.Refer to payer-specific guidelines for the applicable global period.
- Payment Status: Active
- Modifier TC rule: This information is not available in the provided source.Modifier TC rules are payer-specific and may not always apply to this code.
- Fee Schedule : This information is not available in the provided source.Consult historical Medicare Physician Fee Schedules and payer-specific databases for historical fee data.
- Specialties:Ophthalmology, Oculoplastic Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center