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Enucleation of the eye is a surgical procedure that involves the complete removal of the eyeball (globe) from its socket (orbit). 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 and determines the length of the optic nerve to ensure proper technique and placement of any subsequent implants. 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. Following the division of the optic nerve, the globe is extracted from the orbit. In the context of CPT® coding, this specific code, 65103, refers to enucleation with the placement of an implant that is not attached to the extraocular muscles, distinguishing it from other related codes that involve different techniques and implant configurations.
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Enucleation of the eye is performed for several critical medical indications, primarily related to severe ocular conditions. The following are the explicitly provided indications for this procedure:
The enucleation procedure involves several critical steps, each performed with precision to ensure the safety and effectiveness of the surgery. The following procedural steps are outlined:
After the enucleation procedure, patients typically require careful monitoring and post-operative care to ensure proper healing. The expected recovery period may vary depending on individual circumstances, but patients are generally advised to follow specific guidelines provided by their healthcare team. This may include managing pain, monitoring for signs of infection, and attending follow-up appointments to assess healing and the integration of the implant. Additional considerations may involve counseling and support for the psychological impact of losing an eye, as well as discussions regarding prosthetic options if desired.
| Short Descr | REMOVE EYE/INSERT IMPLANT | Medium Descr | ENUCLEATION EYE IMPLT MUSC X ATTACHED IMPLT | Long Descr | Enucleation of eye; with implant, muscles not attached to 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) | 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). | 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 |
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| Pre-1990 | Added | Code added. |
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