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.
The procedure described by CPT® Code 65265 involves the removal of a non-magnetic foreign body from the posterior segment of the eye. The posterior segment is a significant area within the eye, situated between the lens and the retina, and is filled with vitreous humor, which is a gel-like substance that helps maintain the eye's shape and provides support to the retina. When a foreign body enters this area, it can cause injury and potentially lead to complications if not addressed promptly. During the procedure, the ophthalmologist inspects the eye to determine the exact location of the foreign body within the posterior segment. Depending on the situation, the surgeon may either enlarge the existing wound to access the foreign body or create a new incision to facilitate removal. It is important to note that this code specifically applies to non-metallic foreign bodies; for metallic foreign bodies, a different code (CPT® Code 65260) is used, which involves the use of a magnet for extraction. After the foreign body is successfully removed, the wound is typically closed with sutures as necessary to ensure proper healing.
© Copyright 2026 Coding Ahead. All rights reserved.
The procedure coded as CPT® 65265 is indicated for the removal of non-magnetic foreign bodies located in the posterior segment of the eye. This may occur due to various circumstances, including trauma or accidental injury, where foreign materials penetrate the eye and become lodged in this critical area. The presence of such foreign bodies can lead to significant ocular complications, including inflammation, infection, or damage to the retina, necessitating prompt surgical intervention to preserve vision and prevent further injury.
The procedure for CPT® Code 65265 involves several critical steps to ensure the safe and effective removal of the foreign body from the posterior segment of the eye. Initially, the ophthalmologist conducts a thorough examination of the eye to assess the extent of the injury and locate the foreign body within the posterior segment. This examination may involve the use of specialized imaging techniques or tools to visualize the foreign object accurately.
Post-procedure care following the removal of a foreign body from the posterior segment of the eye is crucial for recovery. Patients may be monitored for any signs of complications, such as infection or inflammation. It is common for patients to receive instructions regarding the use of prescribed medications, such as antibiotics or anti-inflammatory drops, to aid in the healing process. Follow-up appointments are typically scheduled to assess the healing of the eye and ensure that no residual foreign material remains. Patients should also be advised on activity restrictions to avoid strain on the eye during the recovery period.
| Short Descr | REMOVE FOREIGN BODY FROM EYE | Medium Descr | RMVL FB IO FROM POST SEG NONMAGNETIC XTRJ | Long Descr | Removal of foreign body, intraocular; from posterior segment, nonmagnetic extraction | 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 | 20 - Other intraocular 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. | 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.) | 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). | 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) |
|
Date
|
Action
|
Notes
|
|---|---|---|
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.