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The procedure described by CPT® Code 65135 involves the insertion of an ocular implant following the enucleation of the eye, specifically when the extraocular muscles are not attached to the implant. Enucleation refers to the surgical removal of the eye, and this procedure is typically performed in cases of severe trauma, malignancy, or other conditions that necessitate the removal of the eye. During the insertion of the ocular implant, if the eyelid has been previously closed with sutures, these sutures are opened to allow for inspection of the muscle cone, which is the area where the implant will be placed. An appropriately sized ocular implant, made from porous materials such as mesh or biosynthetic substances, is selected for insertion. The design of these implants allows surrounding tissue to grow into the porous structure, which helps to secure the implant within the muscle cone over time. It is important to note that in this specific procedure, the ocular implant is not attached to the extraocular muscles, distinguishing it from other related procedures, such as CPT® Code 65140, where the muscles are sutured to the implant. This distinction is crucial for accurate coding and understanding of the surgical approach taken during the procedure.
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The procedure associated with CPT® Code 65135 is indicated in specific clinical scenarios where enucleation has been performed, and there is a need for an ocular implant without the attachment of extraocular muscles. The following conditions may warrant this procedure:
The procedure for the insertion of an ocular implant following enucleation involves several key steps:
After the insertion of the ocular implant, post-procedure care is essential for optimal recovery. Patients may be monitored for any signs of infection or complications. The healing process involves the surrounding tissue gradually integrating with the porous implant, which may take several weeks. Patients are typically advised on proper care of the surgical site and may be prescribed medications to manage pain and prevent infection. Follow-up appointments are crucial to assess the healing process and ensure that the implant is settling correctly within the muscle cone.
| Short Descr | INSERT OCULAR IMPLANT | Medium Descr | INSJ OC IMPLT AFTER ENCL MUSC X ATTACHED | Long Descr | Insertion of ocular implant secondary; after enucleation, 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) | 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). | 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. | 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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| Pre-1990 | Added | Code added. |
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