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.
Enucleation of the eye, as described by CPT® Code 65105, is a surgical procedure that involves the complete removal of the eyeball (globe) along with the attachment of an implant to the extraocular muscles. This procedure is typically indicated for the treatment of serious conditions affecting the eye, such as intraocular melanoma, which is a type of cancer that originates in the eye, or retinoblastoma, a malignant tumor that primarily affects young children. Additionally, enucleation may be necessary in cases of severe trauma to the eye that cannot be repaired or salvaged. During the procedure, the surgeon carefully measures the globe and determines the length of the optic nerve to ensure proper placement of the implant. The use of a dissecting microscope aids in visualizing the intricate orbital structures and assessing the extent of any lesions or trauma present. A limbal incision is made to access the eye, and the extraocular muscles are meticulously exposed and divided to facilitate the removal of the globe. The optic nerve is then located and severed, allowing for the complete extraction of the eye. Unlike other codes such as 65101, which involves enucleation without an implant, or 65103, where an implant is placed but not attached to the muscles, CPT® Code 65105 specifies that the implant is not only placed in the muscle cone but also that the extraocular muscles are sutured to the implant, providing stability and support for the prosthetic eye.
© Copyright 2026 Coding Ahead. All rights reserved.
Enucleation of the eye is performed for several specific 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 designed to ensure the safe and effective removal of the eye while preparing for the placement of an implant. The following procedural steps are outlined:
After the enucleation procedure, patients typically require careful monitoring and follow-up care. Post-procedure care may include managing pain, preventing infection, and monitoring for any complications related to the surgery. Patients will also need to be educated on the care of the implant and the surrounding area. Recovery time can vary, but patients are generally advised to avoid strenuous activities and follow specific instructions provided by their healthcare provider to ensure optimal healing. Additionally, arrangements for prosthetic eye fitting may be discussed during follow-up visits, as this is an important aspect of restoring appearance and function after enucleation.
| Short Descr | REMOVE EYE/ATTACH IMPLANT | Medium Descr | ENUCLEATION EYE IMPLT MUSC ATTACHED IMPLT | Long Descr | Enucleation of eye; with implant, muscles 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) | 2 - Payment restriction for assistants at surgery does not apply 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 |
| LT | Left side (used to identify procedures performed on the left side of the body) | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 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. | 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. | 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.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | E3 | Upper right, eyelid | 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 | RT | Right side (used to identify procedures performed on the right side of the body) | SG | Ambulatory surgical center (asc) facility service |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.