65101

🩺 CPT 65101 - Enucleation of Eye; Without Implant

Short Definition

Complete surgical removal of the intact eyeball (globe) from the orbit, with severance of all six extraocular muscles and transaction of the optic nerve, without placement of any orbital volume implant into the resulting anophthalmic socket.

Long Definition

CPT 65101 describes enucleation of the eye — the complete surgical excision of the entire intact globe from the bony orbit — performed without insertion of an orbital volume implant at the time of surgery. This is the most fundamental of the three ocular removal procedures: evisceration (65091/65093) removes only intraocular contents while preserving the scleral shell; enucleation (65101/65103/65105) removes the entire globe including the sclera; and exenteration (65110-65114) removes the globe plus all orbital contents including fat, muscles, and periorbita.

The “without implant” designation means that after the globe is removed, the orbit is simply closed — Tenon’s capsule is sutured over the empty socket, conjunctiva is closed, and a temporary conformer is placed. No prosthetic sphere, hydroxyapatite implant, silicone ball, or any other volume-replacing device is inserted. The result is a significantly reduced orbital volume compared to a socket fitted with an implant, which over time can lead to the constellation of findings collectively called anophthalmic socket syndrome: superior sulcus deformity, enophthalmos of the socket, upper eyelid ptosis, lower eyelid laxity, and a deep-set appearance of the prosthetic eye.

Despite these limitations, CPT 65101 (enucleation without implant) remains an appropriate and sometimes preferable choice in specific clinical circumstances:

• Active intraocular infection (panophthalmitis, endophthalmitis): Placing an implant in an infected field carries the risk of implant contamination, orbital cellulitis, or meningeal spread through the optic nerve sheath; enucleation without implant eliminates the risk
• Severe orbital trauma with contamination: Heavily contaminated wounds may preclude immediate implant placement
• Patient preference or financial constraints: Some patients prefer a staged approach — remove the eye now, consider implant placement later
• Patients with poor wound healing capacity: Diabetes, prior radiation to the orbit, or autoimmune conditions may increase implant extrusion risk, making staged or no-implant approaches safer
• Emergency/urgent situations: Speed of surgery may necessitate a simpler approach; secondary implant (65140) can be placed once the patient has recovered
• Pediatric cases with active orbital infection or trauma: When implant safety is uncertain
• Cases where the fellow eye risk from sympathetic ophthalmia demands the fastest possible enucleation

Critically, the absence of an implant at the time of 65101 does not foreclose future implant placement. When the socket has healed and conditions are favorable, a secondary orbital implant can be inserted using CPT 65140 (Insertion of ocular implant secondary; after enucleation, muscles attached to implant). If performed within the 90-day global period of 65101, modifier -58 is applied; if beyond the global period, 65140 is a standalone new surgical episode.

The operative sequence for 65101 includes: (1) 360-degree conjunctival peritomy; (2) identification and isolation of all six extraocular muscles; (3) sequential muscle disinsertion from the globe with locking sutures placed on each muscle stump for orientation; (4) blunt and sharp dissection through Tenon’s capsule to free the globe from surrounding orbital fat; (5) optic nerve transection with scissors or a snare (approximately 10-15 mm posterior to the posterior sclera); (6) removal of the intact globe; (7) meticulous hemostasis of the orbital apex and optic nerve stump; (8) optional: placement of each rectus muscle stump in anticipation of future secondary implant; (9) closure of Tenon’s capsule over the empty socket; (10) conjunctival closure; and (11) placement of a conformer.

Area of Body

Ocular Globe and Orbital Space

• Removed intraoperatively: The complete intact eyeball — sclera, cornea, choroid, iris, ciliary body, retina, vitreous, and crystalline lens — plus approximately 10-15 mm of the optic nerve with its meningeal sheath
• Detached intraoperatively: All six extraocular muscles severed from their scleral insertions; each muscle stump is preserved within the orbit for potential future use (secondary implant surgery)
• Preserved orbital structures: Orbital fat pad, periorbita, lacrimal gland and drainage system, all orbital nerves (infraorbital, supraorbital, trochlear, abducens, oculomotor branches), all four bony orbital walls
• Socket post-operatively (without implant): The orbit contains only empty Tenon’s space filled with orbital fat; without volume replacement, the socket will progressively contract over months to years unless a prosthesis and socket maintenance are performed; orbital fat atrophy and fibrosis of the conjunctival fornices are long-term risks
• Prosthetic interface: After socket healing (6-8 weeks), the ocularist fabricates a custom acrylic or glass ocular prosthesis that rests against the closed conjunctival socket; without a volume implant, the prosthetic eye is typically thicker and heavier (to fill more volume) but motility is limited to conjunctival tissue movement only
• Long-term orbital considerations: Volume deficiency after 65101 without subsequent implant (65140) leads to progressive enophthalmos, superior sulcus deformity, and lower eyelid laxity — often necessitating secondary implant or orbital volume augmentation procedures in the months to years following surgery

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 (Sclera and Muscles Preserved)  
│ ├─ [[65091]] Evisceration; without implant  
│ └─ [[65093]] Evisceration; with implant  
│  
├─ Enucleation of Eye (Complete Globe Removed)  
│ ├─ 65101 ← THIS CODE  
│ │ Enucleation of eye; WITHOUT implant  
│ │ (Entire globe excised; no volume implant placed)  
│ ├─ [[65103]] Enucleation of eye; WITH implant, muscles NOT attached to implant  
│ └─ [[65105]] Enucleation of eye; WITH implant, muscles ATTACHED to implant  
│  
└─ Exenteration of Orbit (Globe + ALL Orbital Contents Removed)  
├─ [[65110]] Exenteration; removal of orbital contents only  
├─ [[65112]] ... with therapeutic removal of bone  
└─ [[65114]] ... with muscle or myocutaneous flap

Secondary/Follow-Up Codes Directly Related to 65101: 65140 Insertion of ocular implant secondary; after enucleation, muscles attached to implant ► The most common staged follow-up to 65101 ► If within 90-day global period of 65101: use modifier -58 ► If beyond global period: bill as new standalone procedure (new global period 090)

65155 Reinsertion of ocular implant; with or without conjunctival graft ► Used if a previously placed secondary implant (65140) requires reinsertion ► Separate session; own global period

65175 Removal of ocular implant ► Used if a secondary implant (from 65140) requires removal ► New global period begins

67550 Orbital implant (implant outside muscle cone); insertion ► Extraconal implant for volume augmentation; distinct from intraconal 65140 ► May be relevant in anophthalmic socket with volume deficiency

67560 Orbital implant (implant outside muscle cone); removal or revision

67900-67999 Repair of Brow, Eyelid, and Orbit ► Socket reconstruction, dermis fat graft, fornix reconstruction codes in this range ► Separately billable if anophthalmic socket complications require later surgical repair

69990 Use of operating microscope (add-on, no modifier -51) ► Report when the surgeon uses the operating microscope during 65101

HCPCS Supply Code (Facility — NOT billed by surgeon): V2623 Prosthetic eye, plastic, stock V2624 Prosthetic eye, plastic, custom ► Ocularist services; billed by ocularist, never by surgeon; outside Global Periods

Includes (Procedures Bundled Into CPT 65101)

The following are integral components of the operative and global package and cannot be separately billed by the same surgeon:

• Pre-operative assessment on the day of surgery (bundled into global)
• Local or topical anesthesia injected by the operating surgeon
• 360-degree conjunctival peritomy at the corneoscleral limbus
• Identification, isolation, and tagging of all six extraocular muscles with muscle hooks
• Sequential disinsertion of all six extraocular muscles from the scleral globe surface
• Blunt and sharp orbital dissection through Tenon’s capsule to develop the surgical plane
• Optic nerve transection with scissors or snare; meningeal sheath management
• Removal of the intact globe in its entirety
• Hemostasis of the optic nerve stump and orbital apex (electrocautery, pressure)
• Tenon’s capsule closure over the empty socket
• Conjunctival closure with absorbable sutures
• Conformer placement to maintain socket contour and fornix depth during healing
• Standard wound dressing, eye pad
• All related post-operative E/M visits within the 90-day global surgical period
• Standard post-operative pain management instructions and prescriptions

Excludes / Separate Billable Services

Excludes — Mutually Exclusive (Same Eye, Same Session):

• 65103 - Enucleation with implant, muscles unattached; use 65103 instead of 65101 if any implant is placed, with muscles NOT sutured to it
• 65105 - Enucleation with implant, muscles attached; use 65105 instead of 65101 if an implant is placed with direct muscle-to-implant suturing
• 65091 / 65093 - Evisceration; a completely different procedure (sclera preserved); mutually exclusive with enucleation for the same eye
• 65110 / 65112 / 65114 - Exenteration; far more extensive orbital content removal; never billed with enucleation for the same session

Excludes — Separately Billable with Documentation:

• 65140 - Secondary orbital implant after enucleation (separate, subsequent encounter); if within the 90-day global period of 65101, use modifier -58; if after 90 days, bill as a new independent service
• 65155 - Reinsertion of ocular implant; separate session
• 65175 - Removal of ocular implant; separate session with new global period
• 67550 - Extraconal orbital implant; separate technique at a separate session for volume augmentation
• 69990 - Operating microscope (add-on; report separately when applicable; no -51 modifier)
• Anesthesia (00140) - Billed separately by anesthesiologist/CRNA
• Surgical pathology (88300-88309) - Tissue submission for pathologic examination billed by pathology department; always submit the globe when malignancy is the indication; 88309 is the appropriate Level VI code for an enucleated eye
• Frozen section (88331) - Intraoperative frozen section analysis of optic nerve margin or other tissue; billed separately by pathology
• Pre-operative A-scan biometry (76516) - Contralateral eye axial length measurement for future implant planning; separately billable at a pre-operative visit on a different date from surgery
• Post-operative orbital imaging - CT orbit (70480-70482) or MRI orbit (70540-70543) ordered after surgery for tumor surveillance or socket assessment; separately billable by radiology
• Ocular prosthesis fitting (V2623, V2624) - Ocularist services for prosthetic eye fabrication; outside physician global period entirely
• Socket reconstruction procedures (67900-67999) - Fornix reconstruction, dermis-fat graft, or tarsal strip procedures for late anophthalmic socket complications; separately billable at subsequent encounters
• Modifier -57 E/M - If the decision for surgery was made during an E/M visit on the day of or day before the procedure (for major surgery), that E/M is separately billable with modifier -57

RVU and Reimbursement Data

CY 2026 Conversion Factors: The CY 2026 Medicare Physician Fee Schedule Final Rule established two conversion factors: (1) $33.4009\ast \ast forphysiciansnotparticipatinginaqualifiedAlternativePaymentModel(APM),representinga3.26$33.5675 for physicians participating in a qualified APM (3.77% increase). The majority of ophthalmology practices use the non-APM conversion factor of $33.4009. Note that the CY 2026 rule also implemented an efficiency adjustment to work RVUs for certain procedures — verify current MPFS values in the CMS PFS Look-Up Tool for your specific locality. For North Carolina providers, use MAC Jurisdiction M (Novitas Solutions), Locality 03 - Rest of North Carolina.

RVU Component	Approx. Value (CY2026)
Work RVU (wRVU)	~10.16
Practice Expense RVU - Facility	~2.68
Practice Expense RVU - Non-Facility	~5.06
Malpractice RVU	~0.48
Total RVU - Facility	~13.32
Total RVU - Non-Facility	~15.70
Estimated Medicare Payment - Facility	~$444.95
Estimated Medicare Payment - Non-Facility	~$524.37

Enucleation Family RVU Comparison (CY2026):

CPT	Description	Approx. wRVU	Estimated Facility Payment
65101	Enucleation without implant	~10.16	~$444.95
65103	Enucleation with implant, muscles unattached	~11.32	~$481.27
65105	Enucleation with implant, muscles attached	~12.13	~$508.26

65101 carries the lowest wRVU in the enucleation family because it does not include implant placement — the incremental surgical work of implant sizing, insertion, and layered closure adds measurable physician effort that is captured in 65103 and 65105. The absence of an implant makes 65101 a technically simpler and faster operation; however, the long-term anophthalmic socket management implications — which fall outside the surgical global and are addressed at separate encounters — must be considered in overall patient care planning.

No facility supply charge: Because no implant is placed, 65101 does not generate an L8610 (Ocular implant) charge for the facility. The facility claim includes only operating room services (revenue code 0360) and standard supply costs.

Assistant at Surgery

• Assistant at Surgery: PAYABLE for CPT 65101
• Medicare assistant-at-surgery indicator: 1 — payment is allowed without restriction
• An assistant surgeon is clinically appropriate for 65101, particularly in cases with dense orbital scarring, active infection, complex pediatric anatomy, intraocular malignancy with risk of orbital spread, or sympathetic ophthalmia cases where rapid, precise optic nerve transection is essential
• Modifier -80: Full MD/DO physician assistant surgeon present for the entire procedure
• Modifier -81: Physician providing only partial/minimal surgical assistance
• Modifier -82: Teaching facility where a qualified surgical resident is not available; documentation of unavailability is required and subject to audit
• Modifier -AS: Required by Medicare when a non-physician provider (PA, NP, CNS) assists at surgery; replaces -80/-81 on the claim; reimbursed at 85% of the physician assistant-at-surgery rate
• Reimbursement: Assistant surgeon receives approximately 16% of the primary surgeon’s Medicare allowable (~$71 at facility rate for 65101)
• Commercial payer variance: Always verify pre-authorization requirements before the procedure; failure to pre-authorize when required results in denial regardless of modifier

Global Surgical Period

Element	Detail
Global Period	090 Days (Major Surgery)
Pre-operative Period	1 day immediately prior to the date of surgery (bundled)
Day of Surgery	Fully included in global package
Post-operative Period	90 days following the operative date
Total Global Window	92 days (1 pre-op + DOS + 90 post-op)
Included Post-op E/M	All related follow-up E/M visits within 90 days are bundled
Unrelated E/M During Global	Bill separately with modifier -24; document clearly as unrelated to eye surgery
Decision for Surgery E/M	If E/M visit the day of or day before surgery resulted in the decision for major surgery, use modifier -57 on the E/M
Staged/Related Procedure During Global	Modifier -58 (e.g., secondary implant 65140 placed within 90 days of 65101)
Unplanned Return to OR (Complication)	Modifier -78 (e.g., return to OR for socket hemorrhage, wound dehiscence, or orbital hematoma)
Unrelated Procedure During Global	Modifier -79 — new global period begins for the unrelated procedure
Transfer of Surgical Care	-54 (surgery only) + -55 (post-op management only) for the receiving provider

Practical global period note for 65101: The most common planned staged procedure within the 90-day global is secondary orbital implant placement (65140). If the surgeon and patient decide during the post-operative period that an implant is now desired (e.g., patient has recovered well and tolerates anesthesia), 65140 within the global period requires modifier -58. Beyond 90 days, 65140 is billed independently with no modifier. All follow-up socket care visits within the global are bundled — the ocularist prosthesis fitting visits are not physician visits and do not fall under the physician global period.

Common Modifiers for CPT 65101

Modifier	Name	When to Use with 65101
-RT	Right Side	Procedure on right eye — always required; claim will be rejected without laterality
-LT	Left Side	Procedure on left eye — always required
-50	Bilateral Procedure	Simultaneous bilateral enucleation without implant — rare; 150% payment adjustment; verify payer preference (single line -50 vs. two lines -RT / -LT-51)
-57	Decision for Surgery	E/M visit on day of or day before major surgery during which the decision to operate was made; appended to the E/M code, not the surgical code
-80	Assistant Surgeon (MD/DO)	Full physician surgical assistant for entire case
-81	Minimum Surgical Assistant	Physician providing only limited assistance
-82	Assistant - No Resident Available	Teaching facility; document resident unavailability
-AS	Non-Physician Assistant at Surgery	PA/NP/CNS assisting; Medicare requires this modifier instead of -80
-22	Increased Procedural Services	Substantially increased surgical complexity (e.g., previously irradiated orbit, dense orbital scarring from prior surgery, severe orbital infection with tissue destruction); requires supporting documentation and written justification; may yield 15-30% additional payment if approved by payer
-52	Reduced Services	Procedure partially completed (e.g., operation abandoned due to patient instability; document and consider whether the work performed supports a lesser code)
-53	Discontinued Procedure	Procedure terminated after initiation due to patient safety or medical emergency
-54	Surgical Care Only	Surgeon performs surgery; transfers post-op management to another provider
-55	Post-op Management Only	Provider accepting post-op care; must document transfer and start date
-58	Staged/Related Procedure During Global	Planned return to OR within global period (e.g., 65140 secondary implant placement within 90 days of 65101)
-59	Distinct Procedural Service	Separate, distinct same-day service not ordinarily performed together; use only with clear documentation and when NCCI edit otherwise would bundle the service inappropriately
-62	Two Primary Surgeons	Rarely applicable; two surgeons each performing distinct, separately documentable portions of a complex orbital procedure requiring different surgical expertise
-73	Discontinued at ASC (Pre-Anesthesia)	Procedure cancelled at ASC before anesthesia induction; no surgeon fee billed separately
-74	Discontinued at ASC (Post-Anesthesia)	Procedure discontinued after anesthesia induction at ASC; reduced payment applies
-78	Unplanned Return to OR (Related)	Complication during global period requiring OR return (e.g., orbital hemorrhage, severe socket infection, wound dehiscence)
-79	Unrelated Procedure During Global	Completely unrelated surgical procedure during global period; a new global period begins
-24	Unrelated E/M During Global	E/M visit for a completely unrelated problem during global period; must be clearly documented as unrelated to the eye surgery
-GC	Resident Under Teaching Physician	Attestation required per Medicare teaching physician rules when a resident participates
-GE	Primary Care Resident Exception	Not applicable for this surgical procedure

MS-DRG Mapping (Inpatient Only)

CPT 65101 is most commonly performed as an outpatient procedure (ASC or hospital outpatient). Inpatient admission is appropriate when the underlying condition — intraocular malignancy requiring chemotherapy coordination, severe orbital infection, significant systemic comorbidities, or pediatric cases requiring anesthesia monitoring — necessitates inpatient-level care. In the inpatient setting, ICD-10-PCS codes (not CPT) drive DRG assignment.

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

CC/MCC impact on DRG assignment: The difference in hospital reimbursement between DRG 124 (with MCC) and DRG 126 (without CC/MCC) can exceed $6,000-$10,000 depending on the geographic wage index. Thorough physician documentation of all comorbidities — particularly panophthalmitis (H44.01x, a CC), diabetes with complications, active malignancy, or systemic infection — is essential to accurate DRG assignment and appropriate facility reimbursement. Coders should query physicians when documentation is ambiguous.

Malignancy DRG routing: When enucleation is performed for retinoblastoma (C69.21/C69.22) or choroidal melanoma (C69.31/C69.32) in a pediatric or adult inpatient, the principal diagnosis sequencing is critical. The neoplasm may route the case to MDC 17 (Hematological and Solid Neoplasms) rather than MDC 02 depending on the grouper logic and which condition was chiefly responsible for the admission. Sequence the principal diagnosis per UHDDS guidelines — the condition established after study to be chiefly responsible for the admission.

ICD-10-PCS Equivalent for Inpatient Coding:

ICD-10-PCS Element	Value
Section	0 - Medical and Surgical
Body System	8 - Eye
Root Operation	T - Resection (complete removal of a body part without replacement)
Body Part	8 - Eye, Right / 9 - Eye, Left
Approach	0 - Open
Device	Z - No Device (no implant placed — this is what differentiates the PCS code from 65103/65105 equivalents)
Qualifier	Z - No Qualifier

ICD-10-PCS code string for 65101, right eye: 08T80ZZ — Resection of Right Eye, Open approach, No Device, No Qualifier ICD-10-PCS code string for 65101, left eye: 08T90ZZ — Resection of Left Eye, Open approach, No Device, No Qualifier

Common Diagnosis Codes Used with CPT 65101

ICD-10-CM Code	Description	Clinical Notes
H44.511	Absolute glaucoma, right eye	End-stage glaucoma; most common indication in adults; painful blind eye with no visual potential
[H44.512	Absolute glaucoma, left eye	Same — left eye
H44.513]	Absolute glaucoma, bilateral	Bilateral — rare; use modifier -50 for simultaneous bilateral procedure
H44.521	Atrophy of globe (phthisis bulbi), right eye	Severely shrunken, non-functional, disfiguring eye
H44.522	Atrophy of globe (phthisis bulbi), left eye	Same — left eye
H44.011	Panophthalmitis, acute, right eye	Active severe infection; 65101 (no implant) preferred over 65103/65105 to prevent implant seeding
H44.012	Panophthalmitis, acute, left eye	Same — left eye
H44.019	Panophthalmitis, acute, unspecified eye	Use only when laterality genuinely cannot be determined
C69.21	Malignant neoplasm of retina, right eye	Retinoblastoma in children; always submit globe for pathology; consider staging implications
C69.22	Malignant neoplasm of retina, left eye	Same — left eye
C69.31	Malignant neoplasm of choroid, right eye	Uveal/choroidal melanoma; most common primary intraocular malignancy in adults
C69.32	Malignant neoplasm of choroid, left eye	Same — left eye
C69.41	Malignant neoplasm of ciliary body, right eye	Ciliary body melanoma
C69.42	Malignant neoplasm of ciliary body, left eye	Same — left eye
C69.11	Malignant neoplasm of cornea, right eye	Less common; corneal malignancy with globe invasion
C69.91	Malignant neoplasm of eye, unspecified, right eye	Use when histologic type pending or multifocal; update when pathology finalizes
C69.92	Malignant neoplasm of eye, unspecified, left eye	Same — left eye
S05.21xA	Ocular laceration/rupture with prolapse or loss of intraocular tissue, right eye, initial encounter	Catastrophic traumatic globe rupture not amenable to repair; 65101 without implant when contamination precludes primary implant
S05.22XA	Same — left eye, initial encounter
H44.131	Sympathetic uveitis, right eye	Preventive enucleation of the inciting injured eye; document which eye is inciting vs. fellow
H44.132	Sympathetic uveitis, left eye	Same — left eye as inciting eye
H44.121	Parasitic endophthalmitis, unspecified, right eye	Rare; enucleation may be necessary for severe cases
H44.122	Parasitic endophthalmitis, unspecified, left eye	Same — left eye
Q11.1	Cryptophthalmos	Congenital ocular malformation; pediatric indication
Q11.2	Microphthalmos	Severe congenital microphthalmos with no visual potential
H05.421	Enophthalmos due to atrophy of orbital tissue, right eye	May be sequela code used during post-operative follow-up documentation
H05.422	Enophthalmos due to atrophy of orbital tissue, left eye	Same — left eye; documents the socket volume deficiency expected after 65101 without implant
Z90.01	Acquired absence of right eye	Status code used after enucleation for ongoing medical record documentation; not used on the surgical claim itself but important in post-operative records
Z90.02	Acquired absence of left eye	Same — left eye

Coding Tip - Z90.0x Status Codes: After enucleation, the patient’s ongoing medical record should reflect the acquired absence with Z90.01 (right) or Z90.02 (left). These codes are appropriate secondary codes in outpatient visits post-operatively and in any future encounters where the enucleated eye status is clinically relevant. They should not be used as the primary diagnosis on the surgical claim itself.

Coding Tip - Malignancy sequencing: For neoplasm-driven enucleation, sequence the malignancy (C69.xx) as the principal/first-listed diagnosis. The admission or encounter is primarily for surgical treatment of the cancer. Secondary diagnosis codes for any associated conditions (e.g., absolute glaucoma as a complication of the tumor, retinal detachment) may be added when documented and clinically pertinent.

Coding Tip - Trauma seventh characters: For traumatic enucleation indications, use seventh character A (initial encounter) on the operative date. For follow-up visits related to the traumatic injury within the global period, use D (subsequent encounter). For any late effects or sequelae that develop, use S (sequela) with an appropriate sequela code.

Coding Examples

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Example 1 - Absolute Glaucoma, Left Eye, ASC, Without Implant (Patient Declines Implant)

Clinical Scenario: A 71-year-old female presents with a painful, cosmetically disfigured left eye secondary to end-stage absolute glaucoma (H44.512). Visual acuity is no light perception (NLP). She has failed cyclocryotherapy twice. The patient and surgeon discuss enucleation with vs. without implant; the patient declines implant at this time due to cost and concerns about a second surgical material in her body. She prefers to be referred to an ocularist for a prosthesis and consider secondary implant later if desired. The surgeon performs enucleation without implant. No operating microscope used.

CPT Coding:

• 65101-LT - Enucleation of eye; without implant (left eye)

ICD-10-CM:

• H44.512 - Absolute glaucoma, left eye

Place of Service: 24 (Ambulatory Surgical Center)

Post-operative Planning:

• Follow-up visits within 90 days: bundled under 65101-LT global package
• Ocularist referral for prosthesis fitting (V2624): not part of surgeon’s global; ocularist bills separately
• If patient later desires secondary implant: 65140-LT (after global period ends — no modifier needed; if within 90 days, use -58)
• Document patient’s informed refusal of implant in the medical record for audit protection

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Example 2 - Panophthalmitis, Right Eye, Emergency, Implant Deferred Due to Infection

Clinical Scenario: A 55-year-old diabetic male presents emergently with acute bacterial panophthalmitis, right eye (H44.011), with no light perception and extensive intraocular purulence. The ophthalmologist determines enucleation is necessary. Given the active infection and risk of implant seeding leading to orbital cellulitis or intracranial spread, the surgeon performs enucleation without implant. Systemic IV antibiotics administered. Globe sent to pathology and microbiology.

CPT Coding:

• 65101-RT - Enucleation of eye; without implant (right eye)

ICD-10-CM:

• H44.011 - Panophthalmitis, acute, right eye (Note: CC for inpatient DRG purposes)
• E11.9 - Type 2 diabetes mellitus without complications (comorbidity — relevant to infection susceptibility and healing; if with complications, code to higher specificity)

Place of Service: 21 (Inpatient Hospital — admitted for IV antibiotics and monitoring)

MS-DRG Note: H44.011 qualifies as a CC (Complication/Comorbidity) in the MS-DRG system (v37+). If the patient also has a qualifying MCC (e.g., septicemia A41.9), the case routes to DRG 124. With only CC-level comorbidities, DRG 125 applies. Without either, DRG 126. Accurate documentation of diabetic complications and infection severity is critical to DRG accuracy.

Pathology:

• 88309 - Level VI Surgical pathology; eye, enucleated (billed by pathology)
• Microbiology culture and sensitivity (87070 or appropriate code) billed by laboratory

Future Coding Note: Once infection has fully resolved (typically 2-3 months), the surgeon may discuss secondary implant. At that time, 65140-RT (secondary orbital implant after enucleation) would be billed as a new episode of care with its own global period.

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Example 3 - Retinoblastoma, Right Eye, Pediatric Inpatient, Optic Nerve Margin Critical

Clinical Scenario: A 3-year-old male is diagnosed with unilateral group E retinoblastoma, right eye (C69.21), refractory to chemotherapy. The pediatric ophthalmologist performs enucleation without implant — implant deferred due to the child’s age, small orbital volume, and preference to place a growing implant (conformer series) to stimulate orbital growth. The globe is removed with a long optic nerve segment (~15 mm) to ensure clear surgical margins. Globe submitted for pathology with special request for optic nerve margin frozen section. Child is admitted pre-operatively for pre-anesthesia labs and post-operatively for chemotherapy coordination.

CPT Coding:

• 65101-RT - Enucleation of eye; without implant (right eye)

ICD-10-CM:

• C69.21 - Malignant neoplasm of retina, right eye (retinoblastoma)

ICD-10-PCS (Inpatient Facility):

• 08T80ZZ - Resection of Right Eye, Open approach, No Device, No Qualifier

Pathology (Billed by Pathology Department):

• 88309 - Level VI; eye, enucleated (malignant neoplasm)
• 88331 - Intraoperative frozen section; optic nerve margin (billed separately by pathology if performed)

MS-DRG Consideration: With principal diagnosis C69.21 (retinoblastoma), the grouper may route to MDC 17 (Hematological/Solid Neoplasms) rather than MDC 02. Facility coders should confirm DRG routing before final billing. Chemotherapy coordination during the inpatient stay may further affect DRG assignment if chemotherapy is administered during the same admission.

Pediatric Socket Management Note: The pediatric enucleated orbit requires progressive conformer expansion (not an implant initially) to stimulate bony orbital growth and prevent hemifacial hypoplasia. Conformer exchanges are performed by the ocularist at regular intervals. These are non-physician services and fall entirely outside the surgeon’s global period.

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Example 4 - Sympathetic Ophthalmia Prevention, Left Eye as Inciting Eye

Clinical Scenario: A 40-year-old male sustained penetrating trauma to the left eye 5 weeks ago. He now develops early sympathetic uveitis in the right (fellow) eye (H44.131). The ophthalmologist discusses the risk to the right eye and, after discussion of all options, the patient consents to enucleation of the left (inciting) eye without implant to reduce the antigenic stimulus. Speed of surgery is prioritized; implant discussion is deferred. No implant placed.

CPT Coding:

• 65101-LT - Enucleation of eye; without implant (left eye — the inciting injured eye)

ICD-10-CM (carefully sequenced):

• H44.132 - Sympathetic uveitis, left eye (the inciting eye being removed — principal diagnosis)
• H44.131 - Sympathetic uveitis, right eye (the threatened fellow eye — additional diagnosis)
• S05.22xD - Ocular laceration and rupture with prolapse or loss of intraocular tissue, left eye, subsequent encounter (the original injury — seventh character D)

Place of Service: 22 (On Campus Outpatient Hospital) or 21 if admitted

Documentation Alert: The operative report must unambiguously identify the left eye as the inciting (injured) eye being removed and the right eye as the threatened fellow eye. Wrong-site surgery risk in this scenario is exceptionally high. Pre-operative “time-out” documentation confirming laterality is medically, legally, and regulatorily mandatory. A single documentation error confirming the wrong laterality could result in catastrophic vision loss.

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Example 5 - Enucleation with Increased Complexity, Prior Orbital Radiation

Clinical Scenario: A 68-year-old female with history of orbital radiation (Gy total dose 50) for a previously treated intraocular lymphoma now requires enucleation of the right eye for a painful, blind, radiation-injured eye with phthisis bulbi (H44.521) and failed conservative management. The orbital dissection is significantly complicated by radiation fibrosis, dense adhesions of Tenon’s capsule and orbital fat, friable conjunctival tissue, and abnormal tissue planes requiring substantially longer operative time and greater surgical complexity than a routine enucleation. No implant is placed due to radiation-compromised tissue and high implant extrusion risk.

CPT Coding:

• 65101-RT-22 - Enucleation of eye; without implant (right eye); increased procedural complexity

ICD-10-CM:

• H44.521 - Atrophy of globe (phthisis bulbi), right eye
• H05.10 - Chronic inflammatory disorders of orbit (radiation-related; or use the appropriate sequela/late effect code)
• Z85.840 - Personal history of malignant neoplasm of eye (prior intraocular lymphoma)

Modifier -22 Requirements:

• A brief written justification letter submitted with the claim explaining the substantially increased complexity
• Operative note must explicitly document: radiation-induced fibrosis, dense adhesions, abnormal tissue planes, estimated operative time vs. typical time, and specific technical challenges encountered
• Without this documentation, payer will typically deny the -22 upcharge even if surgery was genuinely more complex
• Expect a 15-30% payment increase if approved; some payers require prior authorization for -22

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Example 6 - Secondary Orbital Implant After 65101 (Within Global Period)

Clinical Scenario: The same patient from Example 1 (65101-LT for absolute glaucoma) returns 6 weeks post-operatively. She has reconsidered and now desires an orbital implant for improved prosthetic fit and cosmesis. The socket appears well-healed. The surgeon plans secondary implant placement (65140) at week 7 post-operatively — still within the 90-day global period of 65101.

CPT Coding:

• 65140-LT-58 - Insertion of ocular implant secondary; after enucleation, muscles attached to implant (left eye; modifier -58 = staged/related procedure within the global period of 65101)

ICD-10-CM:

• H44.512 - Absolute glaucoma, left eye (ongoing underlying condition)
• Z90.02 - Acquired absence of left eye (status code documenting prior enucleation)

Modifier -58 Impact: CMS pays the full allowed amount for 65140 when billed with modifier -58; it does not reduce payment because -58 is used for planned staged procedures, not unplanned complications (-78). A new 90-day global period begins for 65140 starting on the date of the secondary implant surgery.

Documentation Requirement: The medical record must support the staged nature of the procedure — document that at the time of the original 65101, implant was intentionally deferred, and the current encounter represents the planned staged second phase of socket rehabilitation.

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Example 7 - Bilateral Enucleation Without Implant (Bilateral Retinoblastoma)

Clinical Scenario: A 2-year-old child with bilateral advanced retinoblastoma (group D/E bilateral) requires bilateral enucleation. Both eyes are enucleated without implant during the same operative session; conformer series will be used bilaterally for orbital growth stimulation.

CPT Coding — Option A (Medicare/CMS preference):

• 65101-50 - Enucleation of eye; without implant (bilateral; single line item with -50)

CPT Coding — Option B (some commercial payers prefer two lines):

• 65101-RT - Right eye
• 65101-LT-51 - Left eye (multiple procedures modifier)

ICD-10-CM:

• C69.21 - Malignant neoplasm of retina, right eye
• C69.22 - Malignant neoplasm of retina, left eye

Tip

Always confirm the individual payer’s billing preference for bilateral procedures before submission. Medicare and most CMS-aligned payers prefer modifier -50 on a single line item and pay 150% of the single-procedure allowed amount. Many commercial payers prefer two line items with -RT and -LT, with the second line using modifier -51 (multiple procedure reduction). Billing incorrectly for a given payer’s requirement will result in a denial or overpayment that must be refunded.

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Surgical Documentation Requirements

To support medical necessity for CPT 65101 and protect against audit denials, the following documentation elements must be present:

Pre-operative record:

• Documented diagnosis establishing no useful visual potential (visual acuity: NLP, or light perception only, with corroborating clinical findings)
• Specific indication for enucleation (pain, infection, malignancy, trauma, sympathetic ophthalmia risk)
• Documentation of failed or inappropriate conservative treatment
• Informed consent discussion — including the decision not to place an implant at this time and the rationale (infection risk, patient preference, deferred staging, radiation history, etc.)
• If malignancy: pre-operative imaging report confirming extent; tumor board discussion documentation when available

Operative note must explicitly state:

• Procedure performed: “enucleation of the [right/left] eye without implant”
• Muscle management: all six muscles isolated, disinserted, and tagged/stump preserved
• Optic nerve: transected approximately [x] mm posterior to the globe; describe snare vs. scissors approach
• Globe delivered intact (or note if delivery was complicated)
• Hemostasis achieved; orbital apex and nerve stump cauterized
• Tenon’s closure technique and suture material
• Conjunctival closure
• Conformer placed; size documented
• Specimen disposition: “globe submitted to pathology” (mandatory for malignancy; strongly recommended for all enucleations)
• Explicit absence of implant placement (this distinguishes 65101 from 65103/65105)

Post-operative note requirements:

• Each post-operative visit note should reference “post-operative visit following [65101-RT/LT, date of surgery]” to clearly tie the visit to the global package
• Document socket healing progress, conformer status, patient tolerability, and plans for prosthetic fitting or secondary implant discussion
• Any complications, unplanned interventions, or return-to-OR events must be clearly documented with modifier justification

NCCI Edit Awareness

Edit Relationship	Action Required
65101 + 65103 (same eye, same session)	Mutually exclusive — use only one; 65103 includes implant work
65101 + 65105 (same eye, same session)	Mutually exclusive — the implant placement and muscle attachment technique determines the correct code
65101 + 65091/65093 (same eye)	Mutually exclusive — enucleation and evisceration are distinct procedures
65101 + 65110-65114 (same session)	Mutually exclusive — exenteration is a distinct, more extensive procedure; never bill with enucleation for the same eye
65101 + 65140 (same session)	Edits may apply — 65140 is a secondary implant code; it should not be billed same session as 65101; if implant is placed at the same time, use 65103 or 65105 instead
65101 + conjunctival repair codes	May be bundled; use modifier -59 only with documentation of a clearly distinct, separately identifiable conjunctival repair for a separate indication
MUE = 1 per day per eye	Only one unit of 65101 per eye per operative session; multiple units will deny without exceptional documentation
69990 with 65101	Add-on code; do NOT apply -51 modifier; no laterality modifier required on 69990; report separately when documented