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2025 CPT code 65140

Insertion of a secondary ocular implant after enucleation, with muscle attachment.

Adhere to the official CPT coding guidelines for ophthalmological procedures and the general guidelines for surgical procedures.Specific coding guidelines might apply based on the implant type, the approach taken, and any additional procedures performed concurrently. Consult the current CPT manual and payer-specific guidelines.

Modifiers may apply depending on the circumstances.For example, modifier 51 (Multiple Procedures) may be used if additional procedures are performed during the same session.Modifier 22 (Increased Procedural Services) may be used in exceptional circumstances if the procedure is significantly more complex than usual. Consult the CPT manual and payer-specific guidelines for appropriate modifier usage.

Medical necessity for this procedure is established by the need to restore the anatomy and function of the eye socket after enucleation, improving cosmetic appearance and facilitating normal movement of the artificial eye.

The ophthalmologist or qualified surgeon is responsible for the entire procedure, including patient preparation, socket preparation, implant insertion, muscle attachment, and closure. Post-operative care and follow-up are also part of the clinical responsibility.

IMPORTANT:65135 (Insertion of ocular implant secondary; after enucleation, muscles not attached to implant) is used when the muscles are not attached to the implant.65150 (Reinsertion of ocular implant; with or without conjunctival graft) describes reinsertion of an existing implant.

In simple words: The doctor puts in a permanent artificial eye after the real eye has been removed.The artificial eye is attached to the muscles that move the eye, making it look more natural.

This CPT code, 65140, describes the surgical procedure of inserting a secondary ocular implant into the eye socket following enucleation (removal of the eyeball).The procedure involves attaching the implant to the extraocular muscles responsible for eye movement. This is typically performed several months after the initial enucleation. The procedure includes preparing the socket, inserting the implant, suturing the rectus muscles to the implant, closing Tenon's capsule and the conjunctiva, and placing an orbital conformer.

Example 1: A patient undergoes enucleation due to a traumatic eye injury. Several months later, an ocular implant is inserted and attached to the extraocular muscles to restore the eye socket's shape and allow for normal eye movement., A patient with a history of retinoblastoma undergoes enucleation, and later receives an implant with muscle attachment for cosmetic and functional restoration., A patient experiences complications with a previously implanted prosthesis requiring removal and replacement with a new implant, including muscle reattachment using code 65140.

* Preoperative diagnosis and indications for the procedure.* Documentation of previous enucleation.* Detailed operative report including description of implant type, muscle attachment technique, and closure method.* Postoperative course and any complications.* Pathology report (if applicable).* Photographs (before and after surgery, if applicable).

** Always refer to the most up-to-date CPT codebook and payer-specific guidelines for complete and accurate coding.Understanding the difference between ocular and orbital implants is crucial for accurate coding.This procedure may be bundled with other services based on payer policy.

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

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