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2025 CPT code 65175

Removal of an ocular implant located within the eye's muscular cone.

Adhere to all applicable CPT coding guidelines.Use modifiers as needed to reflect any adjustments to the procedure (e.g., -22 for increased procedural services, -52 for reduced services).Consult payer-specific coding guidelines.

Modifiers may be applicable based on the specific circumstances of the procedure.Examples include -22 (Increased Procedural Services), -52 (Reduced Services), -53 (Discontinued Procedure), -54 (Surgical Care Only), -55 (Postoperative Management Only), -56 (Preoperative Management Only), -58 (Staged or Related Procedure), and others.

Medical necessity for removal of an ocular implant is established by the presence of infection, implant extrusion/exposure, recurrent inflammation, pain, visual impairment, or any other significant complication that necessitates intervention.Documentation must clearly support the need for removal to ensure appropriate reimbursement.

The ophthalmologist or qualified surgeon is responsible for performing the surgical procedure.This includes preoperative assessment, patient preparation and anesthesia, surgical removal of the implant, and postoperative care.

IMPORTANT:For orbital implant removal (implant outside the muscle cone), use code 67560.Other codes for removal of implanted material may apply depending on the location (anterior/posterior segment, intra/extraocular) and specifics of the implant.Unlisted codes may be necessary in certain complex cases.

In simple words: The doctor removes an artificial eye from inside the eye socket. This is done carefully to avoid damaging surrounding tissues.The artificial eye is usually not replaced at the same time.

This procedure involves the surgical removal of an ocular implant (artificial eye) situated within the muscular cone of the extraocular muscles of the eye.The surgeon carefully removes the implant, excising any attachments to extraocular muscles while avoiding damage to surrounding tissues.Preoperative preparation and anesthesia are administered.Conjunctival tissue and Tenon's capsule may be excised and retracted to access the implant. Replacement of the implant is typically not performed during the same procedure.

Example 1: A patient presents with an infected ocular implant that is causing discomfort and vision impairment.The surgeon performs a removal of the implant under general anesthesia to resolve the infection., A patient's ocular implant has become dislodged and requires removal due to significant discomfort and potential damage to the surrounding structures.The surgeon meticulously removes the implant to prevent further damage., A patient experiences recurrent exposure of an ocular implant, with signs of inflammation.Surgical removal of the implant is deemed necessary to address the ongoing issue and prevent further complications.

Complete medical history, including details about the original implant surgery and any subsequent complications.Preoperative and postoperative notes, including assessment of infection (if present).Surgical report detailing the procedure performed, including any complications encountered and the condition of the surrounding tissues.Imaging studies (e.g., photographs, OCT scans) before and after the procedure.

** Always ensure that documentation accurately reflects the procedure performed and supports medical necessity.When in doubt, consult with a coding specialist or refer to the AMA CPT manual for detailed coding guidelines.

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