Need help choosing the right code?
Ask CasePilot about procedures, modifiers, bundling, and coding guidance.
Try CasePilot© Copyright 2026 American Medical Association. All rights reserved.
Evisceration of the eye, as described by CPT® Code 65091, is a surgical procedure that involves the removal of the ocular contents while leaving the scleral shell intact. This procedure is typically indicated for patients suffering from severe eye infections that do not respond to antibiotic treatment, as well as for those experiencing significant pain or discomfort in a blind eye. The goal of evisceration is to alleviate pain and improve the cosmetic appearance of the affected eye. During the procedure, the cornea is excised, allowing access to the internal structures of the eye. An ocular curette is then utilized to carefully scrape away the internal ocular contents, which include the retina, uveal tract, vitreous body, and lens, from the scleral shell. To manage any bleeding that may occur from the vortex veins and central retinal artery during this process, electrocautery and/or pressure techniques are employed. After the ocular contents have been removed, the scleral shell is meticulously inspected, and any residual uveal tissue is cleared using a swab. It is important to note that in this specific code, no implant is placed within the scleral shell, distinguishing it from related procedures such as CPT® Code 65093, where an implant is inserted to provide structural support.
© Copyright 2026 Coding Ahead. All rights reserved.
The evisceration of ocular contents is performed under specific clinical circumstances. The following indications are explicitly recognized for this procedure:
The evisceration procedure involves several critical steps to ensure the safe and effective removal of ocular contents. The following procedural steps are outlined:
Post-procedure care following evisceration of ocular contents is essential for optimal recovery. Patients may experience some discomfort and swelling in the area, which can be managed with prescribed pain relief medications. It is important for patients to follow their healthcare provider's instructions regarding wound care and any prescribed medications to prevent infection. Regular follow-up appointments may be necessary to monitor the healing process and address any complications that may arise. Since no implant is placed in this procedure, the focus will be on ensuring the scleral shell heals properly and that the patient adjusts to the changes in their ocular structure.
| Short Descr | REVISE EYE | Medium Descr | EVISCERATION OCULAR CONTENTS W/O IMPLANT | Long Descr | Evisceration of ocular contents; without implant | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 0 - Payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Surgical procedure on ASC list in CY 2007; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P4E - Eye procedure - other | MUE | 1 | CCS Clinical Classification | 21 - Other extraocular muscle and orbit therapeutic procedures |
| 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | GW | Service not related to the hospice patient's terminal condition | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.