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Enucleation of the eye refers to the surgical procedure that involves the complete removal of the eyeball from its socket. This procedure is typically indicated for the treatment of serious conditions such as tumors of the eye, including intraocular melanoma and retinoblastoma, as well as for cases of severe trauma that compromise the integrity of the eye. During the enucleation process, the surgeon carefully measures the globe of the eye and determines the length of the optic nerve to ensure precise removal. The procedure is performed under magnification using a dissecting microscope, which aids in visualizing the intricate orbital structures and assessing the extent of any lesions or trauma present. A limbal incision is made around the conjunctiva and Tenon's capsule to access the eye. The extraocular muscles, which control eye movement, are then exposed and divided to facilitate the removal of the globe. The optic nerve is located and severed, allowing for the complete extraction of the eyeball. It is important to note that in CPT® Code 65101, the enucleation is performed without the placement of an implant, distinguishing it from other codes that involve the insertion of an implant to replace the removed eye.
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Enucleation of the eye is performed for specific medical conditions and circumstances that necessitate the removal of the eyeball. The following indications are explicitly recognized for this procedure:
The enucleation procedure involves several critical steps to ensure the safe and effective removal of the eye. The following procedural steps are outlined:
After the enucleation procedure, specific post-operative care is essential for the patient's recovery. The patient will typically be monitored for any immediate complications, such as bleeding or infection. Pain management is also a critical component of post-procedure care, as patients may experience discomfort following the surgery. Follow-up appointments will be necessary to assess healing and to discuss any further treatment options, including the potential for prosthetic eye placement in the future, if desired. The recovery period may vary depending on individual circumstances, but patients are generally advised to avoid strenuous activities and to follow the surgeon's instructions for care during the healing process.
| Short Descr | REMOVAL OF EYE | Medium Descr | ENUCLEATION OF EYE W/O IMPLANT | Long Descr | Enucleation of eye; 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) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | 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 |
| 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). | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 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 | 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 |
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