65093

🩺 CPT 65093 - Evisceration of Ocular Contents; With Implant

Short Definition

Surgical removal of all intraocular contents from within the preserved scleral shell, with immediate placement of a spherical orbital implant (e.g., silicone, polymethylmethacrylate, hydroxyapatite, or porous polyethylene) into the scleral cavity at the time of surgery, to maintain orbital volume and support prosthetic rehabilitation.

Long Definition

CPT 65093 describes the surgical procedure of evisceration of the eye with primary implant placement. Like its companion code 65091 (without implant), evisceration involves the surgical removal of all internal ocular contents — iris, ciliary body, choroid, retina, vitreous, and lens — while leaving the full scleral shell and its attached extraocular muscles completely intact. The critical distinction of 65093 is that a prosthetic orbital volume implant is inserted directly into the emptied scleral shell during the same operative session.

The preserved scleral shell is a key anatomical advantage of evisceration over enucleation. Because the four recti muscles (medial, lateral, superior, inferior rectus), the two oblique muscles, and the entire orbital fibrovascular framework remain undisturbed, the orbital implant benefits from excellent vascular support and the potential for direct integration — particularly when a porous implant material (hydroxyapatite, porous polyethylene) is used. Fibrovascular ingrowth into porous implants over 6-12 months can allow placement of a motility post, enabling the implant to mechanically transfer extraocular muscle movement to the overlying prosthetic eye, yielding superior cosmetic motility compared to non-porous implants or secondary implants.

The operative sequence for 65093 typically involves: (1) peritomy and/or limbal keratectomy (cornea removal for scleral access); (2) complete evisceration of all uveal contents using curettes, evisceration spoons, and irrigation; (3) thorough cauterization of the scleral interior; (4) enlargement of the scleral opening if necessary to accommodate the chosen implant size; (5) insertion of the orbital implant — typically a sphere ranging from 16 mm to 22 mm in diameter — into the scleral shell; (6) closure of the sclera over the implant using absorbable sutures; (7) conjunctival closure; and (8) placement of a conformer in the fornices to maintain socket shape during healing.

The choice of implant material has evolved considerably. First-generation non-porous silicone or PMMA (polymethylmethacrylate) spheres are inexpensive, biocompatible, and carry low extrusion risk. Second-generation porous implants — most notably hydroxyapatite (HA) derived from coral (Bio-Eye®) or synthetic HA, and porous polyethylene (Medpor®) — allow fibrovascular ingrowth and optional pegging. The surgeon’s implant choice is guided by the indication, the state of the socket, patient preference, cost, and the surgeon’s experience. Implant size is selected based on the contralateral eye’s axial length (typically measured by A-scan ultrasound) to achieve orbital volume symmetry and prevent the anophthalmic socket syndrome (superior sulcus deformity, enophthalmos, ptosis, and lower lid laxity).

When evisceration with implant is used in the setting of intraocular infection (panophthalmitis), many surgeons defer implant placement to a staged procedure (65130, secondary implant after evisceration) to minimize the risk of implant infection, orbital cellulitis, or meningitis from contaminated scleral contents. The “with implant” designation of 65093 presumes the patient and clinical circumstances are appropriate for primary implant insertion.

Area of Body

Eye - Globe, Sclera, and Orbital Apex

• Removed intraoperatively: Cornea (for surgical access), iris, ciliary body, choroid, retina, vitreous body, crystalline lens, and all uveal tissue
• Retained structures: Full-thickness scleral shell with all extraocular muscle attachments intact; optic nerve and its meningeal sheaths; orbital fat pad and all surrounding orbital structures
• Implant placement zone: Intrascleral cavity — the implant occupies the space formerly filled by the vitreous and posterior uveal structures
• Porous implant fibrovascular ingrowth: Over weeks to months post-operatively, blood vessels and fibrous connective tissue from the scleral bed grow into the porous implant matrix, anchoring it biologically within the orbit
• Secondary prosthetic interface: Once the conjunctiva heals and the socket matures (typically 6-8 weeks), an ocularist custom-fabricates an ocular prosthesis that rests over the conformer/implant interface. Superior motility with porous implants may eventually allow a motility post to be drilled into the implant (coded separately as 65125).

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]] Evisceration of ocular contents; WITHOUT implant  
│ └─ 65093 ← THIS CODE  
│ 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; 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 (Used after fibrovascular ingrowth into porous implant; billed at separate session) 65130 Insertion of ocular implant secondary; after evisceration, in scleral shell (Used when 65091 was previously performed and implant is placed at a later date; if within 90-day global period of 65091, use modifier -58) 65155 Reinsertion of ocular implant; with or without conjunctival graft (Used when a previously placed implant was removed and requires reinsertion) 65175 Removal of ocular implant (Used when the 65093 implant requires removal due to extrusion, infection, or migration; a new global period begins)

Add-On Code Often Reported with 65093: 69990 Use of operating microscope (add-on; do NOT append modifier -51)
Report when the operating microscope is required for intraoperative magnification.
Separately payable when documented; not covered by all payers.

Includes (Procedures Bundled Into 65093)

The following services are considered integral to the procedure and part of the 90-day global surgical package. They cannot be billed separately on the same date by the same surgeon:

• Pre-operative evaluation on the day of surgery (bundled into global)
• Local/topical anesthesia administered directly by the operating surgeon
• 360-degree peritomy and limbal keratectomy (corneal removal for access)
• All intraocular content removal (evisceration) — curette, spoon, and irrigation work
• Sizing and selection of the orbital implant from available inventory on the day of surgery
• Insertion and positioning of the orbital implant into the scleral shell
• Scleral closure over the implant with absorbable sutures
• Conjunctival closure
• Placement of a conformer to maintain socket contour
• Routine hemostasis, cauterization, and irrigation
• Wound dressing, eye patch application
• All post-operative visits related to normal recovery within the 90-day global period
• Standard post-operative pain and infection management instructions

Excludes / Separate Billable Services

The following services are not bundled into 65093 and may be billed separately with appropriate documentation:

Excludes — Different Procedure (Mutually Exclusive):

• 65091 - Evisceration without implant; mutually exclusive with 65093 for the same eye at the same session — use only one code to describe the complete procedure
• 65101 / 65103 / 65105 - Enucleation procedures; a completely distinct technique from evisceration; never bill enucleation and evisceration together for the same eye
• 65110-65114 - Exenteration of orbit; far more extensive resection; distinct from evisceration in scope and indication

Excludes — Add-On / Separately Billable:

• 69990 - Operating microscope (report separately as add-on if applicable and documented)
• 65125 - Pegging of the implant (separate encounter, typically months later after fibrovascular ingrowth is confirmed by Tc-99m bone scan or gadolinium-enhanced MRI)
• 65130 - Secondary implant after evisceration (used when implant was not placed at the time of 65091 and is placed later)
• 65175 - Removal of the implant (separate encounter, new global period)
• Anesthesia (00140) - Billed separately by the anesthesiologist/CRNA
• Surgical pathology (88300-88309) - Any tissue submitted for pathologic examination is billed by the pathology department, not the surgeon
• Ocular conformer fitting / prosthesis fitting (V2623, V2624) - Ocularist services; outside the physician global period
• A-scan ultrasound (76516) - Biometry of the contralateral eye for implant sizing; separately billable if performed by the physician at a pre-operative visit with distinct medical decision-making documentation. Do not bill on the day of surgery unless truly a separate service.
• Post-operative imaging (e.g., MRI orbit for fibrovascular ingrowth assessment) - Separately billable by radiology

RVU and Reimbursement Data

Note

Note: RVU values reflect the CY 2026 Medicare Physician Fee Schedule Final Rule, which implemented a -2.5% efficiency adjustment to work RVUs for the majority of non-time-based services effective January 1, 2026. The CY 2026 national conversion factor is approximately $32.35-$32.74 (varies by geographic locality GPCI adjustment). All values below are approximate national non-adjusted estimates. Use the CMS MPFS Look-Up Tool with your specific locality code for precise values — North Carolina falls under MAC Jurisdiction M (Novitas Solutions), Locality 03 - Rest of North Carolina.

RVU Component	Value (Approx. CY2026)
Work RVU (wRVU)	~11.15 (post -2.5% adjustment from ~11.43)
Practice Expense RVU - Facility	~2.82
Practice Expense RVU - Non-Facility	~5.20
Malpractice RVU	~0.53
Total RVU - Facility	~14.50
Total RVU - Non-Facility	~16.88
Estimated Medicare Payment - Facility	~$468.83
Estimated Medicare Payment - Non-Facility	~$545.88

65093 carries a slightly higher wRVU than 65091 (without implant) because of the additional operative complexity involved in implant sizing, preparation, scleral accommodation, and primary closure over the implant. The difference in payment reflects this incremental surgical work and the greater intraoperative risk of implant-related complications (extrusion, migration, exposure).

Implant cost note: The orbital implant itself is typically billed separately by the facility as a supply/device charge (revenue code 0278 - Medical/Surgical Supplies, Implants). The surgeon’s fee (CPT 65093) covers only the physician work. Hydroxyapatite and porous polyethylene implants may cost $300-$1,500+ depending on type and size; the facility bills this to the payer separately under outpatient or ASC pass-through billing rules.

Assistant at Surgery

• Assistant at Surgery: PAYABLE for CPT 65093
• CPT 65093 carries a surgeon assistant indicator of “1” — payment restrictions do not apply and an assistant surgeon is separately reimbursable
• Use modifier -80 when a second physician (MD/DO) provides full assistant surgeon services for the entire procedure
• Use modifier -81 when the assisting physician provides only a limited portion of surgical assistance
• Use modifier -82 in facilities without a qualified surgical resident available (teaching hospital exception)
• Use modifier -AS when a Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist assists at surgery (required by Medicare instead of -80/-81/-82 for non-physician providers)
• The assistant surgeon is typically reimbursed at 16% of the primary surgeon’s Medicare allowable
• Non-physician assistant surgeons billing with -AS are reimbursed at 85% of the physician assistant rate (i.e., 85% × 16% = ~13.6% of the primary allowable) under Medicare
• For commercial payers, always verify the specific payer’s assistant surgery policy — some require pre-authorization, some require written documentation of medical necessity for the assistant, and some capitate or deny assistant services altogether

Global Surgical Period

Element	Detail
Global Period	090 Days (Major Surgery - 90-day global)
Pre-operative Period Included	1 day immediately preceding the date of surgery
Day of Surgery	Included in global package
Post-operative Period	90 days following the date of surgery
Total Global Package Window	92 days total (1 pre-op + DOS + 90 post-op)
Included Post-op E/M Visits	All related follow-up E/M visits are bundled; no separate billing
Unrelated E/M During Global	Billable with modifier -24 (clearly documented as unrelated to surgery)
Staged/Related Procedure During Global	Modifier -58 (e.g., implant pegging procedure 65125 within 90 days)
Unplanned Return to OR (Related Complication)	Modifier -78 (e.g., re-operation for implant exposure)
Unrelated Procedure During Global Period	Modifier -79 (new global period begins for that procedure)
Transfer of Post-op Care	Modifier -54 (surgery only) and -55 (post-op only)

Note

Practical tip for 65093 global period management: The most common staged procedure within the 90-day global of 65093 is implant pegging (65125), which is performed months after fibrovascular ingrowth is confirmed — typically 6-12 months post-evisceration. Since this falls well outside the 90-day global, modifier -58 will generally not be needed for 65125. However, if early surgical revision of the socket or wound dehiscence repair is required within the 90 days, careful modifier selection is essential.

Common Modifiers for CPT 65093

Modifier	Name	When to Use with 65093
-RT	Right Side	Procedure on right eye — always required for laterality identification
-LT	Left Side	Procedure on left eye — always required
-50	Bilateral Procedure	Simultaneous bilateral evisceration with implant — very rare; 150% payment adjustment
-80	Assistant Surgeon (MD/DO)	Physician assistant for the full procedure
-81	Minimum Surgical Assistant	Physician providing partial/minimal surgical assistance
-82	Assistant (No Resident Available)	Teaching facility without available qualified surgical resident
-AS	Non-Physician Assistant at Surgery	PA, NP, or CNS assisting at surgery — required by Medicare in place of -80/-81
-54	Surgical Care Only	Surgeon performs surgery, transfers post-op care to another provider
-55	Post-op Management Only	Provider accepts post-op care from transferring surgeon
-58	Staged Procedure	Planned staged procedure during the global period (e.g., early socket revision within 90 days)
-59	Distinct Procedural Service	Separate, distinct service same day (use for distinct services with NCCI modifier bypass need)
-62	Two Primary Surgeons	Rarely applicable; complex orbital reconstruction requiring two surgeons each performing distinct components
-78	Unplanned Return to OR (Related)	Complication requiring return to OR during global (e.g., implant extrusion, wound dehiscence, orbital hemorrhage)
-79	Unrelated Procedure During Global	Completely unrelated surgical procedure during global period; new global period begins
-24	Unrelated E/M During Global	E/M visit during global period for a distinctly separate, unrelated condition; requires documentation
-52	Reduced Services	Procedure partially performed or abandoned prior to completion
-73	Discontinued at ASC (Pre-Anesthesia)	Procedure cancelled before anesthesia induction at ASC
-74	Discontinued at ASC (Post-Anesthesia)	Procedure discontinued after anesthesia induction at ASC
-GC	Resident Under Teaching Physician Supervision	Teaching physician attestation for Medicare teaching rules compliance
-GE	Resident Without Teaching Physician Present	Used in primary care exception programs — not typical for this procedure

MS-DRG Mapping (Inpatient Only)

CPT 65093 is primarily an outpatient procedure. When performed in the inpatient hospital setting (POS 21), DRG assignment is based on ICD-10-PCS codes, not CPT codes. The DRG grouper uses the principal diagnosis and any surgical procedures coded from the ICD-10-PCS system to assign the appropriate DRG.

MDC	Description	DRG Assignment
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

ICD-10-PCS Equivalent for Inpatient Coding: The inpatient equivalent of 65093 maps most closely to:

• Root Operation: T - Resection or D - Extraction (depending on specific coder documentation review)
• Body System: 0 - Central Nervous System and Cranial Nerves (eye coded as 8 - Eye)
• Body Part: 8 - Eye, Right or 9 - Eye, Left
• Approach: 0 - Open
• Device: 0 - Synthetic Substitute (for non-porous implant) or K - Nonautologous Tissue Substitute or J - Synthetic Substitute depending on implant type
• Qualifier: Z - No Qualifier

Note

Note: The ICD-10-PCS body part coding for evisceration is nuanced because the sclera is preserved. Abstract the root operation and body part characters based on the primary operative objective (removing intraocular contents) and the specific implant device character from the ICD-10-PCS device character table for the Eye body system. The facility coding team bears responsibility for ICD-10-PCS coding; CPT 65093 is used for physician professional fee billing only.

Important

DRG Financial Impact: DRG 124 (with MCC) typically carries a CMS base payment weight significantly higher than DRG 126 (without CC/MCC). The difference in reimbursement to the hospital facility between DRG 124 and DRG 126 can range from approximately $3,000to$8,000+ depending on the hospital’s geographic wage index. Thorough documentation of comorbidities (MCCs and CCs) by the operating surgeon and attending physician is critical to accurate DRG assignment.

Common Diagnosis Codes Used with CPT 65093

ICD-10-CM Code	Description	Notes / Indication Rationale
H44.511	Absolute glaucoma, right eye	End-stage painful blind eye; most common indication; implant improves orbital volume symmetry
H44.512	Absolute glaucoma, left eye	Same — left eye
H44.513	Absolute glaucoma, bilateral	Bilateral (rare); use modifier -50 with 65093
H44.521	Atrophy of globe (phthisis bulbi), right eye	Chronically shrunken, non-functional globe; evisceration restores orbital volume
H44.522	Atrophy of globe (phthisis bulbi), left eye	Same — left eye
H44.011	Panophthalmitis, acute, right eye	When infection is controlled and surgeon judges implant placement safe at primary surgery
H44.012	Panophthalmitis, acute, left eye	Same — left eye; if active infection, consider 65091 (no implant) instead
C69.21	Malignant neoplasm of retina, right eye	Intraocular malignancy; primary implant when surgical margins are adequate
C69.22	Malignant neoplasm of retina, left eye	Same — left eye
C69.41	Malignant neoplasm of ciliary body, right eye	Uveal melanoma — ciliary body, right
C69.42	Malignant neoplasm of ciliary body, left eye	Same — left eye
C69.91	Malignant neoplasm of eye, unspecified, right eye	Use when histology type pending or unspecified
C69.92	Malignant neoplasm of eye, unspecified, left eye	Same — left eye
S05.21xA	Ocular laceration and rupture with prolapse or loss of intraocular tissue, right eye, initial encounter	Traumatic globe rupture; primary implant when socket contamination risk is acceptable
S05.22XA	Same — left eye, initial encounter
H44.121	Parasitic endophthalmitis, unspecified, right eye	Rare; evisceration preferred over enucleation to preserve orbital anatomy
H44.122	Parasitic endophthalmitis, unspecified, left eye	Same — left eye
T85.898A	Other specified complications of other internal prosthetic devices, implants and grafts, initial encounter	When documenting complications related to the implant itself post-operatively

Coding Tip - Laterality Compliance: CMS and most commercial payers require laterality be coded to the highest level of specificity. Always document right eye vs. left eye vs. bilateral in the operative report and confirm laterality modifiers (-RT / -LT) match the ICD-10-CM laterality codes on the claim. A mismatch between -RT and a left-eye ICD-10 code will trigger an edit or denial.

Coding Examples

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Example 1 - Absolute Glaucoma, Right Eye, Primary Hydroxyapatite Implant, Outpatient ASC

Clinical Scenario: A 72-year-old patient has a longstanding diagnosis of end-stage neovascular glaucoma, right eye, with no light perception (NLP vision) and chronic pain unresponsive to cyclocryotherapy and topical medications. The ophthalmologist recommends evisceration with primary hydroxyapatite implant. The procedure is performed at an ASC. The operating microscope is utilized for enhanced visualization of intraocular tissue removal and scleral closure.

CPT Coding:

• 65093-RT - Evisceration of ocular contents; with implant (right eye)
• 69990 - Operating microscope (add-on; no modifier -51)

ICD-10-CM:

• H44.511 - Absolute glaucoma, right eye

Place of Service: 24 (Ambulatory Surgical Center)

Payer Notes:

• Medicare Part B covers 65093 when medical necessity is documented (painful blind eye, no visual potential)
• ASC facility bills implant supply cost separately under HCPCS/revenue code 0278
• Post-op conformer fitting billed by ocularist (V2624); not part of surgeon’s global package

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Example 2 - Phthisis Bulbi, Left Eye, Outpatient Hospital

Clinical Scenario: A 58-year-old patient with a history of ruptured globe from a childhood injury has developed progressive phthisis bulbi of the left eye. The socket has become cosmetically disfiguring and the atrophied globe is causing chronic discomfort. The surgeon performs evisceration with a silicone sphere implant (22 mm) in an outpatient hospital operating room.

CPT Coding:

• 65093-LT - Evisceration of ocular contents; with implant (left eye)

ICD-10-CM:

• H44.522 - Atrophy of globe (phthisis bulbi), left eye

Place of Service: 22 (On Campus Outpatient Hospital)

Coding Note: If the surgeon previously saw this patient in the office to evaluate the need for surgery and that E/M was performed on a different date, the pre-operative E/M is separately billable with modifier -57 (decision for surgery, within 90-day global) if the E/M was on the day before or the day of surgery. Most commonly, pre-operative decisions made weeks before surgery are simply part of standard E/M billing and do not require -57; consult your payer’s global surgery policy for specifics.

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Example 3 - Ocular Melanoma, Right Eye, Primary Implant

Clinical Scenario: A 65-year-old patient is diagnosed with uveal melanoma of the ciliary body, right eye (C69.41). Following oncologic evaluation and informed consent, the surgeon performs evisceration of the right eye with primary insertion of a porous polyethylene (Medpor®) orbital implant. Tissue is sent to pathology. An assistant surgeon (fellow physician) assists for the entire case.

CPT Coding:

• 65093-RT - Evisceration of ocular contents; with implant (right eye) — billed by primary surgeon
• 65093-RT-80 - Same CPT code billed by assistant surgeon with modifier -80

ICD-10-CM:

• C69.41 - Malignant neoplasm of ciliary body, right eye

Pathology (billed by pathology department, not surgeon):

• 88309 - Level VI Surgical pathology; eye, enucleated (also applies to evisceration specimens with uveal melanoma)

Place of Service: 22 (On Campus Outpatient Hospital)

Reimbursement Note: The assistant surgeon bills 65093-RT-80 and receives approximately 16% of the primary surgeon’s Medicare allowable (estimated ~$75). Under commercial payers, assistant surgery reimbursement varies significantly — some pay 20-25% of the primary fee, while others deny without prior authorization.

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Example 4 - Bilateral Evisceration with Implants (Rare)

Clinical Scenario: A 80-year-old patient with bilateral end-stage absolute glaucoma and bilateral painful blind eyes (H44.513 - bilateral) elects to undergo bilateral evisceration with implant placement in a single operative session.

CPT Coding — Option A (Single line item):

• 65093-50 - Evisceration of ocular contents; with implant (bilateral, modifier -50)

CPT Coding — Option B (Two line items, per some payer requirements):

• 65093-RT - Right eye
• 65093-LT-51 - Left eye (multiple surgery modifier; some payers require -51; others prefer -50 on the primary code)

ICD-10-CM:

• H44.513 - Absolute glaucoma, bilateral

Verify payer preference: Medicare prefers modifier -50 on a single line item for bilateral surgical procedures. Many commercial payers prefer two separate line items with -RT and -LT. Confirm the payer’s bilateral surgery submission requirement before billing to avoid claim rejection.

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Example 5 - Complication During Global Period (Return to OR for Implant Exposure)

Clinical Scenario: Three weeks after 65093-RT for absolute glaucoma, the patient presents with implant exposure through a small area of conjunctival wound dehiscence. The surgeon returns the patient to the operating room and performs conjunctival repair over the exposed implant (65270 - Repair of laceration of conjunctiva; or repair by mobilizing conjunctiva).

CPT Coding:

• 65270-RT-78 - Repair of laceration of conjunctiva (related return to OR during global period; modifier -78 identifies this as a complication-related procedure; payment is reduced to intra-service work value only)

ICD-10-CM:

• T85.898A - Other specified complications of other internal prosthetic devices, implants, and grafts, initial encounter

Modifier -78 Note: When modifier -78 is used, Medicare pays the intraoperative (intra-service) portion of the fee only — it does not pay for pre- and post-operative components because those are already included in the 65093 global. The global period does not reset with a -78 procedure; it continues from the original 65093 date of service.

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Example 6 - Staged Implant Pegging After 65093 (Outside Global Period)

Clinical Scenario: Nine months after 65093-LT with a hydroxyapatite implant, fibrovascular ingrowth is confirmed by gadolinium-enhanced MRI. The patient desires improved prosthetic motility. The surgeon drills a peg hole and places a motility post into the hydroxyapatite implant.

CPT Coding:

• 65125-LT - Modification of ocular implant with placement or replacement of pegs

ICD-10-CM:

• H44.512 - Absolute glaucoma, left eye (underlying diagnosis for the original evisceration)
• Z96.1 - Presence of intraocular implant (documenting the current implant status)

Modifier note: Because 65125 occurs 9 months after 65093 — well outside the 90-day global period — no modifier -58 is required. This is a completely separate billable encounter with its own global period (010 days for 65125). A new pre-operative examination should be documented.

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Surgical Documentation Requirements

To support medical necessity and ensure clean claim submission for CPT 65093, the following documentation elements should be present in the medical record:

Pre-operative documentation:

• Diagnosis of a blind, non-functional eye with no useful visual potential (document visual acuity — typically “no light perception” or “light perception only” with chronic pain)
• Evidence of prior conservative management attempted and failed (medications, cyclocryotherapy, etc.)
• Informed consent discussion including choice between evisceration with vs. without implant, and evisceration vs. enucleation
• A-scan biometry of the contralateral eye to guide implant sizing (document axial length and target implant diameter)
• Documentation of absence of active, uncontrolled intraocular infection (distinguishes candidate for 65093 vs. 65091)

Operative note must include:

• Specific confirmation of procedure: “evisceration of ocular contents with implant insertion”
• Description of keratectomy (corneal removal) and access approach
• Description of complete uveal tissue removal including confirmation that all choroidal and retinal tissue was removed
• Type, material, and size of implant inserted (e.g., “22 mm hydroxyapatite sphere,” “20 mm silicone sphere,” “20 mm Medpor porous polyethylene implant”)
• Scleral closure technique and suture material
• Conjunctival closure and conformer placement
• Explicit statement about whether tissue was sent to pathology

Post-operative documentation:

• Follow-up visit notes within 90-day global period should reference “post-operative care following 65093 [date]”
• Documentation of socket healing progress, conformer status, and plans for prosthetic fitting
• Any complications or unplanned interventions must be clearly linked (or separated from) the original 65093 procedure for accurate modifier selection

NCCI Edit Awareness

CPT 65093 is subject to CMS NCCI Procedure-to-Procedure (PTP) edits. Key relationships:

Edit Relationship	Action
65093 bundled with 65091	Mutually exclusive — use only one code for the same eye, same session
65093 bundled with 65101/65103/65105	Mutually exclusive — evisceration and enucleation cannot be billed together for the same eye
65093 bundled with conjunctival repair codes (65270-65286)	May be bundled; use modifier -59 only if a clearly distinct, separately identifiable conjunctival repair was performed for a separate indication
65093 bundled with certain injection codes (67500, 67505)	Review current NCCI edits annually; these are subject to periodic update
MUE of 1	Only one unit of 65093 may be billed per eye per day; multiple units require documentation of exceptional circumstances and MUE adjudication type review