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2025 CPT code 65135

Insertion of an ocular implant after enucleation, without muscle attachment.

Follow all applicable CPT coding guidelines, including those related to surgical procedures of the eye and ocular adnexa.Ensure proper documentation supports the use of this code.

Modifiers may be applicable depending on circumstances, such as 50 (bilateral procedure) if implants are placed in both eye sockets, or other relevant modifiers based on the specific details of the procedure and any add-on codes used.

The medical necessity for this procedure usually stems from the need to restore the shape of the eye socket after enucleation for cosmetic reasons or to create a suitable base for a prosthetic eye. This will typically be supported by the patient’s history and a physician’s clinical evaluation.

The ophthalmologist or other qualified surgeon is responsible for the surgical procedure, including pre-operative preparation, the insertion of the ocular implant, and post-operative care. Anesthesiologists may be involved depending on patient needs.

IMPORTANT:65140 (Insertion of ocular implant secondary; after enucleation, muscles attached to implant) is used when the implant is attached to the eye muscles.Other codes may apply depending on the specific circumstances and additional procedures performed.

In simple words: The doctor puts an artificial eye into the empty eye socket after the eye has been removed.The artificial eye isn't connected to the eye muscles.

This CPT code 65135 describes the surgical procedure of inserting a secondary ocular implant into the eye socket following enucleation (removal of the eyeball).The procedure involves preparing the socket, inserting the implant without attaching it to the extraocular muscles, closing Tenon's capsule and conjunctiva, and placing an orbital conformer.The implant permanently fills the empty socket, and a prosthetic eye may be later fitted over the conjunctiva.

Example 1: A patient undergoes enucleation due to a traumatic eye injury. Several months later, an ocular implant is inserted using code 65135 to restore the shape of the eye socket.No muscle attachment is required., A patient has an eye removed due to cancer. After the healing process, code 65135 is used for insertion of an ocular implant to improve cosmetic appearance. The implant is not attached to the muscles., A patient with a severely damaged eye undergoes enucleation. Following appropriate healing, an ocular implant is placed (65135) to provide a foundation for a custom-fitted prosthetic eye, without muscle reattachment.

* Pre-operative assessment and consent* Surgical report detailing the procedure performed, including the type of implant used, and confirmation that the implant was not attached to the muscles.* Post-operative instructions and follow-up care.* Images (if applicable) to demonstrate the location and type of implant used.

** Always cross-reference this code with other relevant codes to ensure accurate billing.Be mindful of payer specific guidelines and local regulations that influence reimbursement.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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