65103

🩺 CPT 65103 - Enucleation of Eye; With Implant, Muscles Not Attached to Implant

Short Definition

Complete surgical removal of the intact eyeball (globe) from the orbit with severance of all extraocular muscles and the optic nerve, followed by immediate placement of an orbital volume implant into Tenon’s capsule or the orbital fat — with the cut ends of the extraocular muscles sutured to the surrounding tissue (Tenon’s capsule/conjunctiva) rather than directly to the implant surface.

Long Definition

CPT 65103 describes enucleation of the eye with primary orbital implant insertion where the extraocular muscles are not directly attached to the implant itself. This distinguishes it from CPT 65105 (enucleation with implant, muscles attached to implant), where the surgeon sutures each extraocular muscle directly onto a wrapped or bare porous implant to facilitate implant motility coupling with the prosthetic eye.

Enucleation is the complete surgical removal of the entire eyeball — the globe in its entirety — including all intraocular contents (retina, vitreous, lens, uveal tract) contained within the sclera. This is fundamentally different from evisceration (65091/65093), in which the scleral shell and its muscle attachments are preserved while only the intraocular contents are removed. In enucleation, the sclera itself is removed along with everything inside it.

The operative sequence for 65103 typically includes: (1) a 360-degree conjunctival peritomy at the corneoscleral limbus; (2) identification and isolation of all six extraocular muscles (medial, lateral, superior, inferior rectus; superior and inferior oblique muscles) using muscle hooks; (3) detachment of each muscle from the scleral insertion using scissors or cautery, with or without placing a locking suture on each stump for later re-attachment; (4) blunt and sharp dissection of Tenon’s capsule to develop a clean surgical plane between the globe and orbital fat; (5) transection of the optic nerve with scissors or a snare approximately 10-15 mm posterior to the globe; (6) delivery of the intact globe from the orbit; (7) meticulous hemostasis of the optic nerve stump and orbital apex; (8) sizing and selection of the orbital implant (typically 18-22 mm sphere) to approximate the volume of the removed globe; (9) wrapping of the implant in donor sclera, processed pericardium, or polyglactin mesh (if used) to provide a surface for muscle re-attachment — or placement of the implant bare into the posterior Tenon’s space; (10) insertion of the implant into the intraconal space within Tenon’s capsule; (11) closure of Tenon’s capsule over the implant; (12) re-attachment of the four rectus muscle stumps to the anterior Tenon’s capsule or the implant wrap (NOT directly to the bare implant surface — this is what defines 65103 vs. 65105); and (13) conjunctival closure and placement of a conformer.

The Critical Distinction: 65103 vs. 65105

The single most important coding differentiator between these two codes is where the muscles are reattached:

Feature	65103	65105
Muscles attached to implant surface?	No	Yes
Muscles sutured to Tenon’s/wrap/conjunctiva?	Yes	May be, in addition to implant
Motility transfer to prosthesis	Indirect / limited	Superior direct coupling
Typical implant type	Non-porous (silicone, PMMA) or wrapped HA	Porous (hydroxyapatite, Medpor) with direct muscle suturing
Fibrovascular ingrowth potential	Lower (non-porous)	Higher (porous implants)
wRVU	~11.61	~12.45
Surgical complexity	Moderate	Higher

The reasoning behind this distinction is clinical and technical. When muscles are attached directly to a wrapped porous implant (65105), their contractions mechanically couple to the implant, which then transmits movement to the overlying prosthetic eye via a peg or direct contact — yielding superior cosmetic motility. When muscles are not attached to the implant (65103), movement of the overlying prosthesis is driven by socket conjunctival/Tenon’s movement only, producing less natural-appearing eye motion but with a simpler and faster operative technique.

In practice, 65103 is commonly used when: (a) a non-porous implant (silicone sphere, PMMA sphere) is employed and direct muscle attachment to the smooth implant surface is not technically feasible; (b) a wrapped implant is placed but the surgeon elects to secure muscles only to the wrap/Tenon’s closure rather than through the wrap to the implant; or (c) clinical circumstances (infection risk, pediatric patient, emergency trauma surgery) favor a simpler, faster surgical approach. CPT 65105 is typically used when a porous implant (hydroxyapatite, Medpor) is used with direct suturing of each rectus muscle to the implant’s surface or a securing mesh.

Area of Body

Complete Globe and Orbital Space

• Removed intraoperatively: The entire intact eyeball (globe) including sclera, cornea, choroid, retina, vitreous, lens, iris, ciliary body — plus the optic nerve segment (10-15 mm posterior stump)
• Detached intraoperatively: All six extraocular muscles are severed from their scleral insertions; oblique muscles are typically transected closer to the globe
• Preserved structures: Orbital fat pad, periorbita, lacrimal gland, lacrimal drainage apparatus, orbital nerves (infraorbital, supraorbital, trochlear, abducens, oculomotor), all bony orbital walls
• Implant placement zone: Intraconal space within Tenon’s capsule — the implant occupies the posterior orbital volume formerly filled by the globe
• Muscle reattachment in 65103: Rectus muscle stumps are sutured anteriorly to the Tenon’s capsule layer and/or the implant wrap material; the implant itself is not directly sutured to muscles
• Socket anatomy post-operatively: The conformer placed at closure maintains the conjunctival fornices. After 6-8 weeks of healing, an ocularist fabricates a custom acrylic or glass prosthetic eye that rests on the conjunctival surface overlying the implant

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 Preserved)
│ ├─ 65091 Evisceration of ocular contents; without implant
│ └─ 65093 Evisceration of ocular contents; with implant
│
├─ Enucleation of Eye (Globe Completely Removed)
│ ├─ 65101 Enucleation of eye; without implant
│ ├─ 65103 ← **THIS CODE**
│ │ 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

Related Secondary Implant and Implant Modification Codes: 65125 Modification of ocular implant with placement or replacement of pegs (Performed months after fibrovascular ingrowth confirmed; only relevant if a porous implant was used; separate session, separate global period)

65130 Insertion of ocular implant secondary; after evisceration, in scleral shell (Not used after enucleation — this code is specific to post-evisceration)

65140 Insertion of ocular implant secondary; after enucleation, muscles attached to implant (Used when 65101 was previously performed and a secondary implant is now desired; if within 90-day global of 65101, use modifier -58)

65155 Reinsertion of ocular implant; with or without conjunctival graft (Reimplantation after removal of a previously placed implant)

65175 Removal of ocular implant (When the 65103 implant requires removal due to extrusion, migration, or infection; a new global period begins)

67550 Orbital implant (implant outside muscle cone); insertion (Extraconal implant placement — distinct from intraconal 65103)

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

HCPCS Supply Code (Facility Use): L8610 Ocular implant
(Billed by the facility/ASC to represent the cost of the physical
orbital implant device — silicone sphere, PMMA, hydroxyapatite,
or porous polyethylene. NOT billed by the surgeon on the professional claim.)

Add-On Code:

Includes (Procedures Bundled Into 65103)

The following are integral components of the procedure and are included in the 90-day global surgical package. They cannot be billed separately on the same date by the same surgeon:

• Pre-operative assessment on the day of surgery
• Local or topical anesthesia injected by the operating surgeon
• 360-degree peritomy and conjunctival dissection
• Isolation, hooking, and suture-locking of all six extraocular muscles
• Severing each extraocular muscle from its scleral insertion
• Blunt and sharp dissection of Tenon’s capsule and orbital fascia
• Optic nerve transection (standard length ~10-15 mm posterior to the globe)
• Orbital hemostasis and cauterization of the nerve stump
• Sizing and preparation of the orbital implant for insertion
• Implant wrapping (donor sclera, polyglactin mesh, processed pericardium) if performed at the primary procedure — wrapping is bundled when it is part of the primary closure technique
• Implant insertion into Tenon’s capsule / intraconal space
• Anterior Tenon’s capsule closure over the implant
• Reattachment of rectus muscle stumps to Tenon’s capsule / wrap layer (NOT to the bare implant surface)
• Conjunctival closure
• Conformer placement to maintain socket contour
• Standard wound dressing
• All related post-operative visits within the 90-day global period

Excludes / Separate Billable Services

Excludes — Mutually Exclusive (Never Bill Together for Same Eye, Same Session):

• 65101 - Enucleation without implant; mutually exclusive with 65103 for the same eye
• 65105 - Enucleation with implant, muscles attached; use 65105 instead of 65103 if the surgeon directly sutures muscles to the implant surface
• 65091 / 65093 - Evisceration procedures; evisceration and enucleation are distinct surgical techniques; never bill both for the same eye
• 65110 / 65112 / 65114 - Exenteration; vastly more extensive procedure; never billed with or instead of enucleation except when exenteration is the actual procedure performed

Excludes — Separately Billable with Appropriate Documentation:

• 69990 - Operating microscope use (add-on; report separately when applicable and documented)
• 65140 - Secondary orbital implant after enucleation (separate encounter after 65101 was previously performed; if within 90-day global of 65101, use modifier -58)
• 65155 - Reinsertion of ocular implant (after removal of a previously placed implant; separate encounter)
• 65175 - Removal of the orbital implant (separate encounter; new global period)
• 67550 - Orbital implant, insertion outside muscle cone (extraconal placement, distinct from intraconal 65103 implant)
• Anesthesia (00140) - Billed separately by the anesthesiologist/CRNA; not included in surgeon’s fee
• Surgical pathology (88300-88309) - Tissue submission for pathology (mandatory when malignancy is the indication) billed separately by pathology department; always submit the globe specimen when removing for neoplasm
• Frozen section (88331) - If intraoperative frozen section margins are assessed, separately billable by pathology
• A-scan biometry (76516) - Pre-operative ultrasound of the contralateral eye to determine implant size; separately billable at a pre-operative visit distinct from the day of surgery
• Ocular prosthesis fitting (V2623, V2624) - Ocularist services for fabricating and fitting the custom prosthetic eye; outside the physician global period; billed by the ocularist, not the surgeon
• L8610 - HCPCS supply code for the physical orbital implant; billed by the facility/ASC, never by the surgeon on the professional fee claim
• Post-operative imaging - MRI orbit (71552) or CT orbit (70482) ordered during or after the global period for monitoring (e.g., retinoblastoma surveillance, melanoma recurrence) is separately billable by radiology

RVU and Reimbursement Data

CY 2026 Note: All RVU values reflect the CMS CY 2026 Medicare Physician Fee Schedule Final Rule, which applied a mandatory -2.5% efficiency adjustment to work RVUs for all non-time-based services effective January 1, 2026. The CY 2026 national conversion factor is $32.3562 (facility) / variable by locality with GPCI. For North Carolina providers, use MAC Jurisdiction M (Novitas Solutions), Locality 03 - Rest of North Carolina in the CMS MPFS Look-Up Tool for precise geographic payment amounts.

RVU Component	Approx. Value (CY2026)
Work RVU (wRVU)	~11.32 (post -2.5% efficiency adjustment from ~11.61)
Practice Expense RVU - Facility	~3.02
Practice Expense RVU - Non-Facility	~5.45
Malpractice RVU	~0.54
Total RVU - Facility	~14.88
Total RVU - Non-Facility	~17.31
Estimated Medicare Payment - Facility	~$481.27
Estimated Medicare Payment - Non-Facility	~$559.88

Comparison across enucleation family:

CPT	Description	Approx. wRVU (CY2026)	Key Differentiator
65101	Enucleation without implant	~10.16	Lowest complexity; no implant
65103	Enucleation with implant, muscles NOT attached	~11.32	Intermediate; implant placed, muscles to Tenon’s
65105	Enucleation with implant, muscles attached	~12.13	Highest complexity; direct muscle-to-implant suturing

Note

The incremental wRVU difference between 65103 and 65105 reflects the additional surgical time, complexity, and precision required to directly suture each extraocular muscle to the implant surface in 65105 — a more technically demanding maneuver that significantly improves prosthetic motility outcomes.

Tip

Implant device cost (facility): Non-porous silicone or PMMA spheres typically cost $50-$200. Hydroxyapatite implants range from $250-$800. Porous polyethylene (Medpor) implants range from $300-$900. These costs are borne by the facility and billed under HCPCS L8610 or as a supply line item. The surgeon’s professional fee (CPT 65103) does not include device cost.

Assistant at Surgery

• Assistant at Surgery: PAYABLE for CPT 65103
• Medicare assistant-at-surgery indicator: 1 — payment allowed; no restriction applies
• Assistant services are appropriate for this procedure given its complexity (optic nerve transection, orbital dissection, implant placement, multiple muscle management)
• Modifier -80: Full assistant surgeon (MD/DO) present for the entire procedure
• Modifier -81: Physician providing minimal or partial surgical assistance only
• Modifier -82: Used in teaching facilities when a qualified surgical resident is not available; requires documentation of that circumstance
• Modifier -AS: Required by Medicare when the assistant at surgery is a non-physician provider (PA, NP, CNS); replaces -80/-81 on the claim
• Reimbursement rate for assistant surgeon: 16% of the primary surgeon’s Medicare allowable
• Reimbursement rate for non-physician assistant (-AS): 85% of the physician assistant-at-surgery rate (approximately 13.6% of primary allowable)
• Commercial payer caution: Always verify each payer’s assistant surgery policy prior to the procedure. Some plans require written pre-authorization, others deny assistant surgery for “minor” eye procedures, and some cap payment regardless of modifier used. Failure to obtain prior authorization when required will result in denial even with a valid modifier.

Global Surgical Period

Element	Detail
Global Period	090 Days (Major Surgery)
Pre-operative Period Included	1 day immediately prior to the date of surgery
Day of Surgery	Included in the global package
Post-operative Period	90 days following the operative date
Total Global Window	92 days (1 pre-op + DOS + 90 post-op)
Bundled Post-op E/M Visits	All related follow-up included; bill separately only with modifier -24 for unrelated issues
Staged/Related Return to OR	Modifier -58 — planned staged procedure or therapeutic follow-up within global
Complication-Related Return to OR	Modifier -78 — unplanned return to OR during global; only intraservice work paid
Unrelated Procedure During Global	Modifier -79 — new global period begins for the new procedure
Unrelated E/M Visit During Global	Modifier -24 — must document clearly that the visit is for a condition wholly unrelated to the surgery
Transfer of Surgical Care	Modifier -54 (surgery only) and -55 (post-op only)

Global period planning note for 65103: The most common procedures that might occur within the 90-day global include: socket revision for wound dehiscence (-78), implant exposure repair (-78 if unplanned), or a planned staged procedure such as insertion of a motility peg into a porous implant (-58, though pegging typically occurs well beyond 90 days after fibrovascular ingrowth confirmation). Systemic oncology follow-up visits (for retinoblastoma or melanoma patients) are always unrelated to the surgical episode and do not require a modifier.

Common Modifiers for CPT 65103

Modifier	Name	When to Use with 65103
-RT	Right Side	Procedure on right eye — always required; claim will reject without laterality
-LT	Left Side	Procedure on left eye — always required
-50	Bilateral Procedure	Simultaneous bilateral enucleation with unattached implant — extremely rare; 150% payment adjustment; verify payer preference for single line vs. two lines
-80	Assistant Surgeon (MD/DO)	Full physician surgical assistant
-81	Minimum Surgical Assistant	Physician providing minimal assistance
-82	Assistant - No Resident Available	Teaching facility documentation required
-AS	Non-Physician Assistant at Surgery	PA/NP/CNS assisting; Medicare requires this modifier instead of -80
-22	Increased Procedural Services	Substantially increased complexity (e.g., prior radiation to orbit, severe orbital scarring, complex pediatric anatomy); must submit supporting documentation; 15-30% payment increase if approved
-52	Reduced Services	Procedure partially completed (e.g., operation abandoned after globe removal but before implant placement — document and consider whether 65101 would be more accurate)
-53	Discontinued Procedure	Surgery terminated after initiation due to patient safety concern; anesthesia induced but full procedure not completed
-54	Surgical Care Only	Surgeon performs surgery; transfers post-op management to another provider
-55	Post-op Management Only	Provider accepting post-op care from transferring surgeon; must file a transfer of care
-58	Staged Procedure	Planned return to OR within 90-day global for a related staged procedure
-59	Distinct Procedural Service	Separate, distinct same-day service not normally performed with 65103; use only with clear documentation and when NCCI edit otherwise bundles the services
-62	Two Primary Surgeons	Rarely applicable; complex orbital reconstruction with two surgeons performing distinct components requiring distinct expertise (e.g., oculoplastic surgeon + oncologic surgeon)
-66	Surgical Team	Not applicable for standard 65103
-73	Discontinued at ASC (Pre-Anesthesia)	Procedure cancelled at ASC before anesthesia induction; facility bills -73, surgeon does not separately bill
-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, implant extrusion, wound dehiscence)
-79	Unrelated Procedure During Global	Unrelated surgical procedure; new global period begins
-24	Unrelated E/M During Global	E/M visit during global period for a completely unrelated diagnosis; must be documented clearly as unrelated
-GC	Resident Under Teaching Physician	Teaching physician attestation required; key compliance note for residents assisting in eye procedures
-KX	Requirements Met (some payers)	Some DME/supply payers require -KX to indicate medical necessity criteria have been met (relevant to prosthesis billing by ocularist, not surgeon)

MS-DRG Mapping (Inpatient Only)

CPT 65103 is predominantly performed in the outpatient setting (ASC or hospital outpatient department). Inpatient admission is uncommon and typically reserved for cases where the underlying condition — malignancy, pediatric retinoblastoma requiring chemotherapy coordination, severe orbital infection, or significant systemic comorbidities — necessitates inpatient level of care. When admitted, DRG assignment is driven by the ICD-10-PCS surgical code and the principal diagnosis, not the CPT code.

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

Pediatric retinoblastoma note: When enucleation is performed in a pediatric inpatient for retinoblastoma (C69.2x), the DRG grouper may assign to an MDC 17 (Hematological and Solid Neoplasms) DRG rather than MDC 02 depending on the principal diagnosis sequencing. Work with your facility coding team to ensure the principal diagnosis is sequenced correctly per UHDDS guidelines (the condition chiefly responsible for the admission). Sequencing the neoplasm as the principal diagnosis rather than a secondary code can significantly affect DRG assignment and facility reimbursement.

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)
Body Part	8 - Eye, Right / 9 - Eye, Left
Approach	0 - Open
Device	J - Synthetic Substitute (non-porous implant) or K - Nonautologous Tissue Substitute (wrapped implant using donor tissue)
Qualifier	Z - No Qualifier

The ICD-10-PCS device character for 65103 is critical for distinguishing it from 65105 at the inpatient level. A bare non-porous silicone or PMMA implant typically maps to J - Synthetic Substitute. A porous implant (even if used in a 65103 technique) may map to K - Nonautologous Tissue Substitute or a synthetic substitute depending on the implant’s material and the ICD-10-PCS device table entries. Inpatient coders should carefully review the operative report for implant type, material, and attachment details before selecting the device character.

Common Diagnosis Codes Used with CPT 65103

ICD-10-CM Code	Description	Clinical Notes
H44.511	Absolute glaucoma, right eye	End-stage glaucoma; most common indication for enucleation in adults
H44.512	Absolute glaucoma, left eye	Same — left eye
H44.513	Absolute glaucoma, bilateral	Bilateral (rare) — use modifier -50
H44.521	Atrophy of globe (phthisis bulbi), right eye	Severely shrunken, non-functional eye; cosmetic disfigurement and socket discomfort
H44.522	Atrophy of globe (phthisis bulbi), left eye	Same — left eye
C69.21	Malignant neoplasm of retina, right eye	Retinoblastoma in children; uveal melanoma in adults — most common pediatric indication for enucleation
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; poor prognosis if large
C69.42	Malignant neoplasm of ciliary body, left eye	Same — left eye
C69.91	Malignant neoplasm of eye, unspecified, right eye	Use when histologic type pending or unknown; 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	Severe traumatic globe rupture not amenable to repair
S05.22XA	Same — left eye, initial encounter
H44.011	Panophthalmitis, acute, right eye	When infectious source has been addressed; enucleation vs. evisceration choice depends on risk of meningeal spread
H44.012	Panophthalmitis, acute, left eye	Same — left eye
H44.121	Parasitic endophthalmitis, unspecified, right eye	Rare; sympathetic ophthalmia prevention may be indication for enucleation
H44.131	Sympathetic uveitis, right eye	Preventive enucleation of the inciting (injured) eye to prevent sympathetic ophthalmia in the fellow eye
H44.132	Sympathetic uveitis, left eye	Same — left eye
Q11.1	Cryptophthalmos	Pediatric congenital ocular malformation requiring surgical management
T85.318A	Breakdown of other ocular prosthetic devices, implants and grafts, initial encounter	When prior implant has failed and re-enucleation/reimplantation required
T85.328A	Displacement of other ocular prosthetic devices, implants and grafts, initial encounter	Implant migration or extrusion requiring surgical revision
H05.421	Enophthalmos due to trauma or surgery, right eye	May be sequela code used in post-operative follow-up
H05.422	Enophthalmos due to trauma or surgery, left eye	Same — left eye; used when socket volume insufficiency is documented post-enucleation

Tip

Coding Tip - Malignancy sequencing: When enucleation is performed for a primary intraocular malignancy (retinoblastoma, uveal melanoma), the malignancy code (C69.xx) should be the principal/first-listed diagnosis. The encounter is primarily for the surgical treatment of cancer. Any secondary codes for associated conditions (absolute glaucoma, neovascular glaucoma) are coded as additional diagnoses if documented and clinically significant.

Tip

Coding Tip - Traumatic enucleation: When coding for trauma, always use the appropriate seventh character to indicate the encounter type: A (initial encounter), D (subsequent encounter), or S (sequela). For the operative session, use seventh character A. Follow-up visits within the 90-day global period for post-operative care related to the trauma are bundled; use the trauma code with D for any separately billable services outside the global.

Coding Examples

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Example 1 - Absolute Glaucoma, Right Eye, Outpatient ASC, Non-Porous Silicone Implant

Clinical Scenario: A 78-year-old male presents with a painful, blind right eye secondary to end-stage absolute glaucoma. Visual acuity is no light perception (NLP). The patient has failed cyclocryotherapy and topical pain management. The ophthalmologist performs enucleation of the right eye with insertion of a 20 mm silicone sphere orbital implant. The implant is wrapped with polyglactin 910 mesh. Rectus muscles are sutured to the mesh/Tenon’s closure anteriorly — not directly through the wrap into the silicone sphere. No operating microscope used.

CPT Coding:

• 65103-RT - Enucleation of eye; with implant, muscles not attached to implant (right eye)

ICD-10-CM:

• H44.511 - Absolute glaucoma, right eye

Place of Service: 24 (Ambulatory Surgical Center)

Facility Billing Note: The ASC bills L8610 (Ocular implant) for the silicone sphere separately under the facility claim. The surgeon’s professional claim includes only 65103-RT and the ICD-10 code.

Post-operative Plan: After socket healing (6-8 weeks), patient is referred to an ocularist for custom prosthetic eye fitting (V2623 - Prosthetic eye, plastic, custom). All post-op ophthalmology visits within the 90-day global are bundled under 65103-RT.

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Example 2 - Uveal Melanoma (Choroidal), Left Eye, with Assistant Surgeon

Clinical Scenario: A 62-year-old female with a large choroidal melanoma (C69.32) of the left eye undergoes enucleation with primary implant. Due to the size of the tumor and dense orbital vascularity, an oculoplastic surgeon requests an assistant surgeon (fellow ophthalmologist) for the procedure. A wrapped hydroxyapatite implant is inserted but muscles are sutured to the Tenon’s/wrap layer only — not directly into the porous implant surface. Globe specimen is sent to pathology. Operating microscope used.

CPT Coding — Primary Surgeon:

• 65103-LT - Enucleation of eye; with implant, muscles not attached (left eye)
• 69990 - Operating microscope (add-on; no -51 modifier needed)

CPT Coding — Assistant Surgeon (separate claim):

• 65103-LT-80 - Same procedure with assistant surgeon modifier

ICD-10-CM:

• C69.32 - Malignant neoplasm of choroid, left eye

Pathology (billed by pathology department):

• 88309 - Level VI Surgical pathology; eye, enucleated (for malignant neoplasm)

Place of Service: 22 (On Campus Outpatient Hospital)

Reimbursement Note: Assistant surgeon receives approximately 16% of the primary surgeon’s Medicare allowable for 65103. Primary surgeon Medicare allowable (facility rate) estimated at ~$481;assistantsurgeonreceivesapproximately$77.

Important Coding Decision Point: If, instead of the above, the surgeon had sutured each of the four rectus muscles directly through the hydroxyapatite implant wrap into the implant surface using individual muscle-engaging sutures, the correct code would be 65105-LT (muscles attached to implant). The distinction must be clearly documented in the operative note.

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Example 3 - Retinoblastoma, Right Eye, Pediatric Inpatient

Clinical Scenario: A 2-year-old child is diagnosed with unilateral retinoblastoma, right eye (C69.21), that has failed to respond to chemotherapy and local therapies. The pediatric ophthalmologist performs enucleation with primary insertion of a PMMA sphere implant. The child is admitted as an inpatient due to age, anesthesia risk, and planned post-operative chemotherapy coordination. Muscles are sutured to Tenon’s capsule closure, not directly to the smooth PMMA sphere.

CPT Coding:

• 65103-RT - Enucleation of eye; with implant, muscles not attached (right eye)

ICD-10-CM:

• C69.21 - Malignant neoplasm of retina, right eye (retinoblastoma)
• Z3A.00 or appropriate age/demographic codes per facility practice

ICD-10-PCS (Inpatient Facility):

• 08T80JZ - Resection of Right Eye, Open approach, Synthetic Substitute (PMMA sphere), No Qualifier

Place of Service: 21 (Inpatient Hospital)

MS-DRG Consideration: Given principal diagnosis of C69.21 (malignant neoplasm) and the surgical procedure, the grouper may assign MDC 17 (Hematological/Solid Neoplasms) rather than MDC 02. Coordinate with facility HIM/coding team for DRG optimization through accurate comorbidity capture (MCC/CC documentation).

Pathology: Globe specimen submitted for pathology (88309); critical for staging, margin evaluation, and optic nerve resection margin status. Optic nerve margin positivity significantly impacts adjuvant treatment planning — ensure pathology request specifically asks for nerve margin status.

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Example 4 - Sympathetic Ophthalmia Prevention, Left Eye (Inciting Eye)

Clinical Scenario: A 35-year-old male suffered a penetrating injury to the left eye 6 weeks ago with total loss of vision (NLP). He now presents with early sympathetic uveitis in the right (fellow) eye (H44.131). The ophthalmologist discusses enucleation of the left (inciting) eye to prevent further sympathetic stimulation. The patient consents to enucleation of the left eye with implant. Muscles are sutured to Tenon’s closure (not directly to the implant).

CPT Coding:

• 65103-LT - Enucleation of eye; with implant, muscles not attached (left eye)

ICD-10-CM (sequenced carefully):

• H44.132 - Sympathetic uveitis, left eye (the inciting eye being removed)
• H44.131 - Sympathetic uveitis, right eye (the threatened fellow eye — additional diagnosis)
• S05.22xD - Ocular laceration/rupture, left eye, subsequent encounter (the underlying original injury — seventh character D for subsequent encounter)

Place of Service: 22 (On Campus Outpatient Hospital)

Documentation Tip: The operative note must clearly state that the left eye is the inciting (injured) eye being removed to prevent sympathetic ophthalmia in the right (fellow) eye. This laterality distinction is medically and legally significant and must be unambiguous. A wrong-site surgery event in this scenario would be catastrophic — removing the seeing right eye instead of the blind left eye.

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Example 5 - Implant Extrusion During Global Period (Return to OR)

Clinical Scenario: Four weeks after 65103-LT, the patient returns with implant exposure — a 4 mm area of the PMMA sphere is visible through a wound dehiscence. The surgeon takes the patient back to the operating room for conjunctival/Tenon’s repair over the exposed implant.

CPT Coding:

• 65155-LT-78 - Reinsertion of ocular implant; with or without conjunctival graft (related complication return to OR during global period — modifier -78)

Note: Modifier -78 indicates an unplanned return to the OR during the global period for a complication. CMS pays only the intra-service (operative) work value — the pre-operative and post-operative components are not separately payable because they are already included in the 65103 global. The global period of 65103 does not reset or restart with the -78 procedure.

ICD-10-CM:

• T85.318A - Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts, initial encounter (implant exposure/extrusion)
• H05.421 - Enophthalmos due to trauma or surgery, right eye (socket volume issue if applicable)

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Example 6 - Secondary Implant After Prior Enucleation Without Implant (Outside Global)

Clinical Scenario: Eight months ago, the patient underwent enucleation without implant (65101-RT) for absolute glaucoma. The patient now has significant superior sulcus deformity (anophthalmic socket syndrome) and enophthalmos. The surgeon now places a secondary orbital implant with muscle attachment during a separate operative session.

CPT Coding:

• 65140-RT - Insertion of ocular implant secondary; after enucleation, muscles attached to implant

Note: Because this is a secondary implant placed after a prior enucleation (65101), the applicable code is 65140, not 65103. CPT 65103 applies only to primary implant placement at the time of the original enucleation. Since this occurs more than 90 days after the original 65101, no global period modifier is needed and the procedure generates its own new global period.

ICD-10-CM:

• H05.421 - Enophthalmos due to trauma or surgery, right eye
• H44.511 - Absolute glaucoma, right eye (underlying condition)

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Surgical Documentation Requirements

To support medical necessity for CPT 65103 and ensure accurate code assignment (particularly the distinction from 65105), the operative note and pre-operative record must include:

Pre-operative documentation:

• Diagnosis of a blind, painful, cosmetically unacceptable, or malignant eye with no useful visual potential
• Visual acuity documented (NLP or light perception only — quantify)
• Prior treatment history and reasons for failure or inapplicability (conservative management, chemotherapy, radiation, cyclocryotherapy)
• Informed consent discussion: enucleation vs. evisceration options; with vs. without implant; muscle-attached vs. unattached implant; cosmetic outcome expectations
• Pre-operative A-scan biometry of the fellow (contralateral) eye to guide implant size selection
• For malignancy: pre-operative imaging (MRI orbit, CT orbit, ultrasound) confirming extent; discussion of optic nerve margin requirements
• Documentation of absence of active orbital cellulitis or conditions precluding primary implant placement

Operative note must explicitly state:

• Name of the procedure performed: “enucleation of the [right/left] eye with primary orbital implant insertion”
• Confirmation that all six extraocular muscles were identified, isolated, and detached from the globe
• Optic nerve transection: document the estimated length of nerve removed with the globe (10-15 mm optimal)
• Implant type, material, and size (e.g., “20 mm silicone sphere,” “22 mm PMMA sphere,” “20 mm hydroxyapatite sphere wrapped in donor sclera”)
• Critical for code selection: Explicit statement of where muscles were re-attached — “the four rectus muscles were sutured to the anterior Tenon’s capsule / polyglactin mesh wrap” (65103) vs. “the four rectus muscles were sutured directly to the hydroxyapatite implant surface through the wrap” (65105). Ambiguity here creates audit risk.
• Tenon’s capsule and conjunctival closure technique
• Conformer size and placement
• Hemostasis achieved; estimated blood loss
• Disposition of specimen: “globe submitted to pathology” (mandatory for malignancy; document even if deferred)

NCCI Edit Awareness

Edit Relationship	Action Required
65103 + 65101 (same eye, same session)	Mutually exclusive — use only one; 65103 includes the implant work; 65101 does not
65103 + 65105 (same eye, same session)	Mutually exclusive — the muscle attachment technique determines which code is correct; never bill both
65103 + 65091/65093 (same eye)	Mutually exclusive — enucleation and evisceration are distinct procedures; never bill together
65103 + conjunctival repair (65270-65286)	May be bundled; use modifier -59 only with documentation of a separate and distinct conjunctival repair performed for a different, unrelated indication
65103 + 67550 (orbital implant outside muscle cone)	Different anatomical zones; 65103 is intraconal; 67550 is extraconal; if both truly performed at separate sites with documentation, -59 may apply — rare scenario
MUE = 1 per day per eye	Only one unit of 65103 may be billed per eye per operative session; multiple units will deny
69990 with 65103	69990 is an add-on code; do NOT apply -51; always report it separately when the operating microscope is used and documented