Crystal's MCW Coder Hub🩺 CPT 65091 - Evisceration of Ocular Contents; Without Implant
Short Definition
Surgical removal of the internal contents of the eye (iris, lens, vitreous, retina, choroid) through the anterior segment, leaving the scleral shell and its attached extraocular muscles intact, without placement of an orbital implant.
Long Definition
CPT 65091 describes the surgical procedure of evisceration - the removal of all intraocular contents from within the scleral shell - performed without the insertion of a prosthetic orbital implant at the time of surgery. This is one of three primary procedures used for surgical removal of a non-functional, diseased, or painful blind eye, alongside enucleation (complete surgical excision of the globe) and exenteration (removal of all orbital contents). Evisceration is uniquely distinguished from enucleation because the sclera - the tough fibrous white outer coat of the eye - is preserved along with the extraocular muscle attachments it carries. Only the uveal contents and other intraocular structures are removed.
The operative sequence typically involves: (1) a 360-degree peritomy at the corneoscleral limbus or direct corneal incision; (2) removal of the cornea (keratectomy) to allow access; (3) use of an evisceration spoon or curette to scoop out all uveal tissue including the ciliary body, iris, lens, vitreous, retina, and choroid; (4) thorough cauterization and decontamination of the scleral cavity; and (5) closure of the scleral opening without implant placement. When an implant is subsequently placed at a later date or a conformer is placed at the time of surgery, the applicable codes for those services are billed separately.
The “without implant” descriptor is critical to correct code selection. The companion code 65093 (Evisceration of ocular contents; with implant) is used when a spherical or hydroxyapatite implant is inserted into the scleral shell at the time of evisceration. If the physician performs evisceration and later desires to place a secondary implant into the now-empty socket, secondary implant insertion codes (65175) would apply at that subsequent encounter.
The procedure is performed under general anesthesia in most cases, particularly in children or highly anxious patients, though local anesthesia with monitored anesthesia care (MAC) may be used in adults. Evisceration without implant is sometimes chosen as an emergency or salvage procedure in cases of infectious panophthalmitis where implant placement would increase the risk of orbital infection spread.
Area of Body
Eye - Anterior and Posterior Segments of the Globe
- Removed intraoperatively: Cornea (typically removed for surgical access), iris, ciliary body, choroid, retina, vitreous body, lens, and all remaining uveal tissue
- Retained structures: Scleral shell (full thickness), extraocular muscle attachments to the sclera (medial, lateral, superior, inferior rectus; superior and inferior oblique muscles), optic nerve stump within the sclera
- Orbital structures: Orbital fat, periorbita, lacrimal gland, and all orbital nerves remain intact - this is the chief anatomic advantage of evisceration over enucleation
- Socket/prosthetic interface: After healing, the scleral shell becomes the bed over which a prosthetic eye (ocular prosthesis) is fitted. Volume replacement with an implant is typically desired to prevent the anophthalmic socket syndrome (enophthalmos, superior sulcus deformity, ptosis, and lower lid laxity).
CPT Code Hierarchy / Code Tree
Surgery (10004-69990)
└─ Surgical Procedures on the Eye and Ocular Adnexa ([[65091]]-[[68899]])
└─ Surgical Procedures on the Eyeball ([[65091]]-[[65290]])
└─ Removal Procedures of Eye Contents (65091-65114)
│
├─ Evisceration of Ocular Contents
│ ├─ 65091 ← THIS CODE
│ │ Evisceration of ocular contents; WITHOUT implant
│ └─ [[65093]] Evisceration of ocular contents; WITH implant
│
├─ Enucleation of Eye
│ ├─ [[65101]] Enucleation of eye; WITHOUT implant
│ ├─ [[65103]] Enucleation of eye; WITH implant, unattached
│ └─ [[65105]] Enucleation of eye; WITH implant, muscles attached to implant
│
└─ Exenteration of Orbit
├─ 65110 Exenteration of orbit (does not include skin graft),
│ removal of orbital contents; only
├─ [[65112]] ... with therapeutic removal of bone
└─ [[65114]] ... with muscle or myocutaneous flap
Secondary/Related Implant Codes (post-evisceration):
65125 Modification of ocular implant with placement or replacement of pegs
65130 Insertion of ocular implant secondary; after evisceration, in scleral shell
65140 Insertion of ocular implant secondary; after enucleation
65155 Reinsertion of ocular implant; with or without conjunctival graft
65175 Removal of ocular implant
Add-On Code Often Reported with 65091:
69990 Use of operating microscope (add-on code; do NOT append -51)
Report when the surgeon requires the surgical microscope to perform
intraoperative magnification. Not separately payable by all payers.
Includes (Procedures Bundled Into 65091)
The following services are considered part of the global package for 65091 and cannot be billed separately on the same date by the same surgeon:
- Pre-operative evaluation on the day of surgery (included in 90-day global)
- Local or topical anesthesia administered by the operating surgeon
- Routine hemostasis and cauterization during the procedure
- Keratectomy (corneal removal to access the scleral cavity) - integral to the approach
- Scraping/curettage of the scleral cavity for complete uveal tissue removal
- Placement of a temporary conformer (shell-shaped device to maintain socket contour until a permanent prosthesis is fitted) - this is considered part of socket management unless it involves significant separate repair work
- Wound closure of the scleral opening and conjunctival closure
- Post-operative visits for the 90-day global surgical period related to normal recovery
- Post-operative pain management instructions and prescription
Excludes / Separate Billable Services
The following are not included in 65091 and should be billed separately with appropriate documentation of medical necessity and, where required, an NCCI modifier:
Excludes - Different Procedure:
- 65093 - Evisceration with implant; use this code instead of 65091 if an orbital implant is placed at the time of evisceration
- 65130 - Secondary insertion of an orbital implant into the scleral shell after a previous evisceration (65091 only covers the evisceration encounter itself)
- 65101 / 65103 / 65105 - Enucleation procedures; evisceration and enucleation are distinct surgical techniques and should never be billed together for the same eye
- 65110-65114 - Exenteration of orbit; far more extensive procedure with distinct indications
Excludes — Add-On / Separate:
- 69990 — Operating microscope use (add-on; report separately when applicable)
- 67715 — Canthotomy performed at the same session for a separate, distinct indication may be separately payable with -59 modifier
- 65270-65286 — Repair of laceration of the conjunctiva or sclera performed as a distinctly separate service
- Anesthesia — Billed separately by the anesthesiologist/CRNA under anesthesia CPT codes (00140)
- Pathology — Surgical pathology (88300-88309) for tissue specimen submission is billed separately by the pathology department
- Post-op prosthetic fitting — Ocularist services (V2623, V2624 for ocular prosthesis) are non-physician services billed outside the physician global period
RVU and Reimbursement Data
Note: RVU values reflect the CY 2026 Medicare Physician Fee Schedule Final Rule, which includes a -2.5% efficiency adjustment applied to work RVUs for most non-time-based services. The CY 2026 conversion factor is approximately 32.74 (non-facility/facility rates vary by final locality GPCI). Values below are national non-adjusted averages; actual reimbursement will vary by geographic practice cost index (GPCI) locality.
| RVU Component | Value (Approx. CY2026) |
|---|---|
| Work RVU (wRVU) | ~10.61 (post -2.5% adjustment from ~10.86) |
| Practice Expense RVU - Facility | ~2.54 |
| Practice Expense RVU - Non-Facility | ~4.63 |
| Malpractice RVU | ~0.50 |
| Total RVU - Facility | ~13.65 |
| Total RVU - Non-Facility | ~15.74 |
| Estimated Medicare Payment - Facility | ~$441.25 |
| Estimated Medicare Payment - Non-Facility | ~$508.87 |
Note
These are estimates. Use the CMS Medicare Physician Fee Schedule Look-Up Tool (MPFS Search) at cms.gov with your specific locality to obtain the exact allowable for your Raleigh/NC service area (Locality 03 - Rest of North Carolina).
Assistant at Surgery
- Assistant at Surgery: PAYABLE for CPT 65091
- CPT 65091 carries a surgeon assistant indicator of “1” (payment restriction does not apply - assistant is separately billable)
- Use modifier -80 (Assistant Surgeon) when a second physician assists
- Use modifier -81 (Minimum Surgical Assistant) for limited assistance
- Use modifier -82 (Assistant Surgeon when qualified resident surgeon not available) in teaching hospitals without available residents
- The assistant surgeon typically receives 16% of the primary surgeon’s allowable fee under Medicare
- Private payers may vary - always verify payer-specific assistant surgery policies
- Note for incident-to billing: PA/NP assistant at surgery may be reimbursed at 85% of the assistant surgeon allowable under Medicare Part B
Global Surgical Period
| Element | Detail |
|---|---|
| Global Period | 090 Days (Major Surgery - 90-day global) |
| Pre-operative Period | 1 day prior to surgery |
| Day of Surgery | Included |
| Post-operative Period | 90 days following the date of surgery |
| Total Global Package Window | 92 days (1 pre-op + day of surgery + 90 post-op) |
| Included Post-op E/M Visits | All related follow-up visits during global period |
| E/M Visits During Global | Not separately billable if related to the surgery/post-op care |
| Unrelated E/M During Global | Bill with modifier -24 (established patient) |
| Staged/Related Procedure During Global | [[Modifier -58]] |
| Unplanned Return to OR (Related) | [[Modifier -78]] |
| Unrelated Procedure During Global | [[Modifier -79]] |
Common Modifiers for CPT 65091
| Modifier | Name | When to Use with 65091 |
|---|---|---|
| -RT | Right Side | Procedure performed on the right eye - always required for laterality |
| -LT | Left Side | Procedure performed on the left eye - always required for laterality |
| -50 | Bilateral Procedure | Simultaneous bilateral evisceration (rare; bilateral blind eyes); 150% payment adjustment applies |
| -80 | Assistant Surgeon | Physician assistant at surgery |
| -81 | Minimum Assistant | Physician providing minimal surgical assistance |
| -82 | Assistant (No Resident) | In facility without available qualified resident |
| -54 | Surgical Care Only | Surgeon performs surgery but transfers post-op care |
| -55 | Post-op Management Only | Physician accepting post-op care from transferring surgeon |
| -58 | Staged Procedure | Related staged procedure during the 90-day global (e.g., subsequent implant insertion 65130) |
| -62 | Two Surgeons | Rarely applicable; co-surgeons each performing distinct portions |
| -59 | Distinct Procedural Svc | Separate, distinct service on the same day (e.g., conjunctival repair -59 when a separate distinct procedure) |
| -78 | Unplanned Return to OR | Return to OR during global period for complication (e.g., socket hemorrhage, wound dehiscence) |
| -79 | Unrelated Procedure | Unrelated surgical procedure during global period (new global begins) |
| -24 | Unrelated E/M in Global | Evaluation and management visit during global period for a completely unrelated problem |
| -52 | Reduced Services | Procedure partially performed / aborted (document thoroughly) |
| -73 | Discontinued ASC (pre-anesthesia) | Procedure discontinued prior to anesthesia induction at ASC |
| -74 | Discontinued ASC (post-anesthesia) | Procedure discontinued after anesthesia induction at ASC |
| -47 | Anesthesia by Surgeon | Surgeon administers regional/general anesthesia personally - rare for this procedure |
| -AA | Anesthesia by CRNA (Anesthesia use only) | Applicable to the anesthesiologist/CRNA billing 00140 separately |
MS-DRG Mapping (Inpatient Only)
When CPT 65091 is performed in an inpatient hospital setting, the ICD-10-PCS equivalent is used for DRG assignment. The relevant MDC and DRGs are:
| MDC | Description | DRG |
|---|---|---|
| MDC 02 | Diseases & Disorders of the Eye | DRG 124 - Other Disorders of the Eye with MCC |
| MDC 02 | Diseases & Disorders of the Eye | DRG 125 - Other Disorders of the Eye with CC |
| MDC 02 | Diseases & Disorders of the Eye | DRG 126 - Other Disorders of the Eye without CC/MCC |
Note
In most clinical scenarios, 65091 is performed as an outpatient procedure in an ASC (POS 24) or hospital outpatient department (POS 22). Inpatient admission is uncommon unless the underlying pathology (e.g., orbital cellulitis, malignancy, systemic infection) requires it. When inpatient, DRG assignment is driven by the ICD-10-PCS surgical code and the principal diagnosis, not the CPT code.
ICD-10-PCS equivalent (inpatient): The evisceration procedure without implant maps most closely to:
08T(Resection, Eye) body part character specifying the affected eye- Root Operation: T - Resection (partial resection of globe contents) or D - Extraction depending on coder abstraction
- Approach: 0 - Open
Common Diagnosis Codes Used with CPT 65091
| ICD-10-CM Code | Description | Notes |
|---|---|---|
| H44.511 | Absolute glaucoma, right eye | Most common indication; end-stage glaucomatous blind eye |
| H44.512 | Absolute glaucoma, left eye | Same - left eye |
| H44.521 | Atrophy of globe (phthisis bulbi), right eye | Shrunken, non-functional eye after prior trauma or infection |
| H44.522 | Atrophy of globe (phthisis bulbi), left eye | Same - left eye |
| H44.011 | Acute panophthalmitis, right eye | Severe purulent infection; evisceration to preserve orbital anatomy |
| H44.012 | Acute panophthalmitis, left eye | Same - left eye |
| C69.20 | Malignant neoplasm of retina, unspecified eye | Intraocular malignancy requiring removal of globe contents |
| C69.21 | Malignant neoplasm of retina, right eye | |
| C69.22 | Malignant neoplasm of retina, left eye | |
| C69.40 | Malignant neoplasm of ciliary body, unspecified | Uveal melanoma - ciliary body |
| C69.90 | Malignant neoplasm of eye, unspecified | Use specific laterality codes when known |
| S05.20xA | Ocular laceration and rupture with prolapse or loss of intraocular tissue, unspecified eye, initial encounter | Traumatic globe rupture - evisceration as definitive management |
| S05.21xA | Same - right eye, initial encounter | |
| S05.22XA | Same - left eye, initial encounter | |
| H44.121 | Parasitic endophthalmitis, unspecified, right eye | Rare indication; evisceration preferred over enucleation to preserve orbital volume |
| T85.818A | Foreign body in eye following ophthalmic procedure, initial encounter | Post-surgical retained foreign body with globe destruction |
Tip
Coding Examples
Example 1 - Absolute Glaucoma, Left Eye, Outpatient ASC
Clinical Scenario: A 68-year-old patient with a history of end-stage neovascular glaucoma, left eye (H44.512 - Absolute glaucoma, left eye) presents with a chronically painful, non-functional blind eye. The ophthalmologist performs evisceration of ocular contents without implant in an outpatient ASC setting. No implant is placed due to patient preference; a conformer will be placed by the ocularist. Surgical microscope was used.
CPT Coding:
65091-LT- Evisceration of ocular contents; without implant (left eye)69990- Use of operating microscope (add-on; no -51 modifier; not -LT required on this code)
ICD-10-CM:
H44.512- Absolute glaucoma, left eye
Place of Service: 24 (Ambulatory Surgical Center)
Example 2 - Traumatic Globe Rupture, Right Eye, Emergency
Clinical Scenario: A 34-year-old male sustains a penetrating eye injury resulting in catastrophic ocular laceration and rupture with total loss of intraocular tissue, right eye. The ophthalmologist performs emergent evisceration without implant. The patient will be counseled about secondary implant placement (65130) at a future visit.
CPT Coding:
65091-RT- Evisceration of ocular contents; without implant (right eye)
ICD-10-CM:
S05.21xA- Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, initial encounter
Place of Service: 21 (Inpatient Hospital - emergency admission)
Note: If the patient returns within 90 days for secondary implant insertion, bill 65130-RT with modifier -58 (staged procedure within global period) to bypass global period payment denial.
Example 3 - Panophthalmitis, Right Eye, Implant Deferred
Clinical Scenario: A 55-year-old diabetic patient presents with acute bacterial panophthalmitis of the right eye (H44.011). Due to active intraocular infection, the surgeon elects to eviscerate without implant to prevent seeding of an implant with infection. Postoperative IV antibiotics are administered.
CPT Coding:
65091-RT- Evisceration of ocular contents; without implant (right eye)
ICD-10-CM:
H44.011- Panophthalmitis, acute, right eyeE11.9- Type 2 diabetes mellitus without complications (additional comorbidity)
Place of Service: 22 (On-campus outpatient hospital or 21 if admitted)
Example 4 - Uveal Melanoma, Left Eye
Clinical Scenario: A 60-year-old patient with ciliary body melanoma (C69.42 - Malignant neoplasm of ciliary body, left eye) undergoes evisceration of ocular contents without implant as primary surgical management. Tissue is sent to pathology (88309).
CPT Coding:
65091-LT- Evisceration of ocular contents; without implant (left eye)88309- Surgical pathology, gross and microscopic; eye, enucleated (billed by pathology department)
ICD-10-CM:
C69.42- Malignant neoplasm of ciliary body, left eyeZ80.9- Family history of malignant neoplasm (if applicable)
Coding Tip: Specimen handling and pathology charges are bundled into separate departmental billing. Do not include 88309 in the surgeon’s claim.
Example 5 - Staged Procedure / Secondary Implant Insertion (Post-Global)
Clinical Scenario: The same patient from Example 1 (H44.512, left eye) returns 6 months after 65091-LT. The socket has matured and the patient desires an orbital implant for improved prosthetic fit. The surgeon inserts a hydroxyapatite implant into the scleral shell (secondary implant insertion).
CPT Coding:
65130-LT- Insertion of ocular implant secondary; after evisceration, in scleral shell
Note: Because this visit occurs well outside the 90-day global period of 65091, no modifier -58 is needed. The 65130 is billed as a new, independent procedure.
ICD-10-CM:
H44.512- Absolute glaucoma, left eye (ongoing condition driving need for prosthetic rehabilitation)Z96.1- Presence of intraocular lens / prosthetic device (as applicable)
Surgical Note / Documentation Requirements
To support medical necessity for CPT 65091, the operative note and pre-operative documentation should include:
- Diagnosis of a blind, painful, or cosmetically disfigured eye with no useful visual potential
- Documentation of failed conservative management (e.g., cyclocryotherapy, medications for pain control, enucleation vs. evisceration decision-making)
- Specific findings that justify evisceration over enucleation (e.g., preservation of orbital volume, reduced disruption of orbital anatomy)
- Intraoperative description of corneal removal (keratectomy), use of evisceration spoon/curette, complete removal of all uveal contents, cauterization, and wound closure
- Explicit statement that no implant was placed at the time of surgery (distinguishes from 65093)
- Disposition regarding future prosthetic rehabilitation and secondary implant planning
- Specimen submission to pathology if malignancy is suspected or present
NCCI Edits Awareness
CPT 65091 is subject to CMS National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits. Key bundling relationships to be aware of:
- 65091 and 65093 - Mutually exclusive; cannot bill both for the same eye same session
- 65091 and 65101/65103/65105 - Mutually exclusive; evisceration and enucleation of the same eye cannot be billed together
- 65091 and conjunctival/scleral repair codes (65270-65286) - May be bundled unless there is documentation of a separately identifiable service requiring a -59 or X{EPSU} modifier
- MUE: 1 unit per day per eye - billing for more than 1 unit of 65091 per session per eye will be denied without an exception