65105

🩺 CPT 65105 - Enucleation of Eye; With Implant, Muscles Attached to Implant

Short Definition

Complete surgical removal of the entire intact eyeball with transection of the optic nerve, followed by immediate placement of a porous orbital volume implant into Tenon’s capsule, with each extraocular muscle stump directly sutured to the surface of the implant to mechanically couple muscle movement to the implant and optimize prosthetic eye motility.

Long Definition

CPT 65105 represents the highest-complexity code in the enucleation family, describing enucleation of the eye with primary insertion of an orbital implant where all extraocular muscles are directly attached to the implant surface. This is the defining surgical and coding distinction from CPT 65103 (enucleation with implant, muscles NOT attached) and is what justifies the higher wRVU and reimbursement relative to 65101 and 65103.

Enucleation is the complete surgical removal of the entire intact globe — including sclera, cornea, uveal tract, retina, vitreous, and lens — from the bony orbit, with transection of the optic nerve. Unlike evisceration (65091/65093), which preserves the scleral shell and its native muscle attachments, enucleation severs all connections between the muscles and the globe. The extraocular muscles are then re-attached to an implant rather than native tissue, making implant selection and attachment technique critical to long-term functional and cosmetic outcomes.

The clinical rationale for direct muscle-to-implant attachment in 65105 is motility coupling: when the four rectus muscles (medial, lateral, superior, inferior) are sutured directly through the implant wrap and into or onto the porous implant matrix, their coordinated contractions physically move the implant within the orbit. This implant movement is transmitted through the conjunctival surface to the overlying prosthetic eye, producing a natural-appearing, coordinated eye movement. The resulting prosthesis motility is substantially superior to that achieved with 65103 (muscles to Tenon’s only) or 65101 (no implant), where movement of the prosthetic eye depends solely on passive conjunctival tissue displacement.

The operative sequence specific to 65105 distinguishing it from 65103 includes: (1) all standard enucleation steps (peritomy, muscle isolation and disinsertion, optic nerve transection, globe removal, hemostasis); (2) careful selection of an appropriately sized porous implant — typically hydroxyapatite (HA), porous polyethylene (Medpor®), or aluminum oxide (Al₂O₃) — sized to match the volume of the removed globe (usually 18-22 mm diameter); (3) wrapping of the porous implant in donor sclera, processed bovine pericardium (Tutoplast®), polyglactin 910 mesh, or other biological/synthetic wrap material to provide a surface for suture purchase and to reduce implant extrusion risk; (4) insertion of the wrapped implant into the intraconal Tenon’s space; (5) direct suturing of each rectus muscle stump through the anterior wrap to the implant — using either a series of bites through the wrapping material into the implant surface, or by pre-placed holes in the wrap aligned with the four quadrants; (6) optional superior and inferior oblique muscle management (obliques may be sutured to the wrap or allowed to fall naturally); (7) layered Tenon’s capsule closure over the implant; (8) conjunctival closure; and (9) conformer placement.

Why Implant Material Matters for 65105

The direct muscle attachment technique of 65105 requires a porous implant material to achieve long-term security and fibrovascular ingrowth. Non-porous implants (solid silicone spheres, PMMA) have smooth surfaces that cannot be sutured reliably and do not support tissue ingrowth — muscles attached to a smooth non-porous implant will eventually pull free. For this reason:

• 65105 is almost exclusively coded with porous implants (hydroxyapatite, porous polyethylene, bioceramic)
• 65103 is more commonly used with non-porous implants (silicone, PMMA) or when the surgeon elects not to directly attach muscles even with a porous implant
• The ABO (American Board of Ophthalmology) and oculoplastic surgery literature strongly favor porous implants with direct muscle attachment (65105 technique) for optimal long-term cosmetic and functional outcomes

Pegging as a Subsequent Procedure

After fibrovascular ingrowth into a porous implant (typically confirmed by Tc-99m bone scan or gadolinium-enhanced MRI at 6-12 months post-enucleation), a motility post (peg) can be surgically drilled into the anterior implant and engaged by the back surface of the prosthetic eye. This pegging procedure (CPT 65125) is performed as a completely separate session, outside the 90-day global period of 65105, and generates its own global period.

Area of Body

Complete Globe, Orbital Space, and Extraocular Muscle Apparatus

• Removed intraoperatively: The entire intact eyeball — all intraocular and scleral contents — plus approximately 10-15 mm of the optic nerve and its meningeal sheath
• Detached intraoperatively: All six extraocular muscles severed from scleral insertions; muscle stumps preserved in orbit and used for implant attachment
• Direct muscle-to-implant attachment zone: Each of the four rectus muscles is sutured through the implant wrap into the porous implant body; oblique muscles may be attached to the wrap layer. The four rectus muscle attachment points define the four cardinal quadrants of movement that will be transmitted to the prosthesis.
• Preserved orbital structures: Orbital fat, periorbita, lacrimal gland and drainage apparatus, all orbital nerves, all four bony orbital walls
• Fibrovascular ingrowth: Over 6-12 months post-operatively, host blood vessels and fibroblasts penetrate the porous matrix of HA or Medpor implants through the wrap material, anchoring the implant biologically within the orbit and providing a vascular supply that reduces extrusion risk and supports long-term implant viability
• Prosthetic interface: The conformer placed at closure maintains socket anatomy during healing. After socket maturation (6-8 weeks), an ocularist custom-fabricates a prosthetic eye. Superior motility compared to 65103 due to direct muscle coupling. Pegging (65125) further enhances motility when vascularization is confirmed.

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 + Muscles Preserved)  
│ ├─ [[65091]] Evisceration; without implant  
│ └─ [[65093]] Evisceration; with implant  
│  
├─ Enucleation of Eye (Complete Globe Removed)  
│ ├─ [[65101]] Enucleation; WITHOUT implant  
│ ├─ [[65103]] Enucleation; WITH implant, muscles NOT attached to implant  
│ └─ 65105 ← THIS CODE  
│ Enucleation; WITH implant, muscles ATTACHED to implant  
│ (Highest complexity in enucleation family;  
│ porous implant + direct rectus muscle suturing)  
│  
└─ Exenteration of Orbit (Globe + ALL Orbital Contents Removed)  
├─ [[65110]] Exenteration; orbital contents only  
├─ [[65112]] ... with therapeutic removal of bone  
└─ [[65114]] ... with muscle or myocutaneous flap

Directly Related Subsequent Procedure Codes: 65125 Modification of ocular implant with placement or replacement of pegs ► The most common planned staged follow-up to 65105 ► Performed after confirmed fibrovascular ingrowth (6-12 months post-65105) ► Tc-99m bone scan or gadolinium MRI used to confirm ingrowth before pegging ► Typically performed well outside the 90-day global of 65105; no -58 needed ► Own global period: 090 days

65155 Reinsertion of ocular implant; with or without conjunctival graft ► Used when the 65105 implant requires removal and reinsertion ► Separate session; own global period

65175 Removal of ocular implant ► Used when the 65105 implant requires surgical removal (extrusion, migration, infection, implant fracture) ► New global period begins; 65155 or 65140 may be used for reimplantation

65140 Insertion of ocular implant secondary; after enucleation, muscles attached ► Used when 65101 (no implant) was previously performed and implant is now placed at a subsequent session with direct muscle attachment ► If within 90-day global of 65101: modifier -58 ► If beyond 90 days: new episode; own global period

67550 Orbital implant (outside muscle cone); insertion ► Extraconal volume augmentation implant; distinct from intraconal 65105 implant ► May be used adjunctively for volume deficit in the same or later session

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

69990 Use of operating microscope (add-on; no modifier -51) ► Report separately when documented; common with 65105 given fine suturing required for muscle attachment to implant wrapped

HCPCS Supply Codes (Facility billing — NOT surgeon billing): L8610 Ocular implant
► Facility/ASC bills this for the physical porous implant device
► NOT reported on the surgeon’s professional fee claim
► Implant cost varies widely: HA ~$400-$900; Medpor ~$350-$900;
Bioceramic ~$500-$1,200
V2623 Prosthetic eye, plastic, stock (ocularist billing)
V2624 Prosthetic eye, plastic, custom (ocularist billing)
V2625 Enlargement of ocular prosthesis (ocularist billing)

Includes (Procedures Bundled Into CPT 65105)

The following services are integral to the procedure and global package. They cannot be billed separately by the same surgeon on the same date:

• Pre-operative assessment on the day of surgery (global package)
• Local or topical anesthesia injected by the operating surgeon
• 360-degree conjunctival peritomy at the corneoscleral limbus
• Identification, isolation, and disinsection of all six extraocular muscles with locking suture placement on each stump
• Blunt and sharp orbital dissection through Tenon’s capsule to free the globe circumferentially
• Optic nerve transection (scissors or snare); ~10-15 mm stump included with globe
• Delivery of the intact globe from the orbit
• Orbital hemostasis; cauterization of the optic nerve stump and orbital apex
• Implant sizing and selection from available inventory
• Implant wrapping with donor sclera, pericardium, polyglactin mesh, or other wrap material
• Implant insertion into the intraconal Tenon’s space
• Direct suturing of rectus muscles to the implant wrap/surface — the defining component of 65105
• Anterior Tenon’s capsule layered closure over the implant
• Conjunctival closure with absorbable sutures
• Conformer placement to maintain socket contour
• All related post-operative E/M visits within the 90-day global period
• Standard post-operative pain management instructions and prescriptions

Excludes / Separate Billable Services

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

• 65101 - Enucleation without implant; mutually exclusive — if no implant placed, use 65101
• 65103 - Enucleation with implant, muscles NOT attached; mutually exclusive — use 65103 if muscles are attached only to Tenon’s/wrap layer and not directly to the implant
• 65091 / 65093 - Evisceration; a fundamentally different procedure (sclera retained); never coded with enucleation for the same eye
• 65110 / 65112 / 65114 - Exenteration; far more extensive resection; never coded with enucleation for the same eye

Excludes — Separately Billable with Appropriate Documentation:

• 65125 - Implant pegging procedure; performed at a separate session after fibrovascular ingrowth confirmation; typically 6-12 months post-65105; outside the global period — no -58 modifier needed; own global period
• 65155 - Reinsertion of ocular implant; separate encounter
• 65175 - Removal of ocular implant; separate encounter, new global period
• 67550 - Extraconal orbital implant; separate anatomical zone; distinct procedure
• 69990 - Operating microscope (add-on; report separately when documented; no -51 modifier)
• Anesthesia (00140) - Billed separately by anesthesiologist/CRNA
• Surgical pathology (88300-88309) - Globe submitted for pathologic examination; billed by pathology department; 88309 (Level VI; eye, enucleated) applies when malignancy is the indication; always submit the globe
• Frozen section pathology (88331) - Intraoperative optic nerve margin assessment; billed separately by pathology when performed
• Pre-operative A-scan biometry (76516) - Contralateral eye biometry for implant sizing; separately billable at a pre-operative visit on a distinct date from surgery
• MRI orbit with contrast (70543) - Post-operative imaging for fibrovascular ingrowth assessment prior to pegging; separately billable by radiology
• Tc-99m bone scan (78300) - Nuclear medicine imaging used to confirm HA implant vascularization before pegging; billed by nuclear medicine/radiology
• Ocular prosthesis (V2623, V2624, V2625) - Ocularist services; entirely outside the physician global period
• Socket reconstruction (67900-67999) - Late anophthalmic socket complications (fornix reconstruction, dermis-fat graft, tarsal strip) at separate encounters
• Modifier -57 E/M - If the decision for surgery was made the day of or day before the procedure during an E/M visit, 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 $33.4009\ast \ast fornon-APMparticipantsand\ast \ast$33.5675 for qualified APM participants. 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 locality-adjusted payment amounts. RVU values below are approximate national averages.

RVU Component	Approx. Value (CY2026)
Work RVU (wRVU)	~12.13
Practice Expense RVU - Facility	~2.98
Practice Expense RVU - Non-Facility	~5.58
Malpractice RVU	~0.57
Total RVU - Facility	~15.68
Total RVU - Non-Facility	~18.28
Estimated Medicare Payment - Facility	~$523.39
Estimated Medicare Payment - Non-Facility	~$610.49

Full Enucleation Family Comparison (CY2026):

CPT	Description	Approx. wRVU	Est. Medicare Facility Payment	Key Differentiator
65101	Enucleation without implant	~10.16	~$444.95	No implant; fastest; no volume restoration
65103	Enucleation; implant, muscles unattached	~11.32	~$481.27	Implant placed; muscles to Tenon’s only
65105	Enucleation; implant, muscles attached	~12.13	~$523.39	Porous implant; direct muscle-to-implant suturing

Tip

The wRVU premium of 65105 over 65103 (+0.81 wRVU) and over 65101 (+1.97 wRVU) reflects the additional surgical complexity, time, and precision required to: (1) select and wrap a porous implant; (2) align each muscle stump with its correct quadrant on the implant; (3) pass sutures directly through wrap material and into/onto the porous implant body; and (4) achieve secure attachment without tearing the wrap or creating uneven muscle tension. This meticulous step significantly increases operative time and demands greater surgeon skill than the simpler Tenon’s-only closure of 65103.

Tip

Implant device cost note: Porous implants billed by the facility under L8610 vary in cost. Hydroxyapatite spheres range from approximately $400-$900; Medpor (porous polyethylene) from $350-$900; bioceramic implants from $500-$1,200. Some facilities negotiate bundle pricing with vendors. The surgeon’s professional fee (65105) does not include any device cost — that is entirely the facility’s charge.

Assistant at Surgery

• Assistant at Surgery: PAYABLE for CPT 65105
• Medicare assistant-at-surgery indicator: 1 — unrestricted; payment allowed
• An assistant surgeon is clinically well-justified for 65105 given the precision required for direct muscle attachment, particularly in malignancy cases with orbital bleeding risk, dense orbital scarring, or pediatric anatomy
• Modifier -80: Full MD/DO physician assistant for the entire procedure
• Modifier -81: Physician providing minimal or limited surgical assistance only
• Modifier -82: Teaching facility without a qualified resident available; requires contemporaneous documentation of unavailability
• Modifier -AS: Required by Medicare when a non-physician provider (PA, NP, CNS) assists; replaces -80/-81; reimbursed at 85% of the physician assistant-at-surgery rate (~13.6% of primary allowable)
• Reimbursement: Assistant surgeon receives approximately 16% of the primary surgeon’s Medicare allowable (~$84 at facility rate for 65105)
• Commercial payer note: Pre-authorization requirements for assistant at surgery vary significantly across commercial payers. Always verify prior to the date of service to avoid denial.

Global Surgical Period

Element	Detail
Global Period	090 Days (Major Surgery)
Pre-operative Period	1 day immediately prior to the operative date (included)
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)
Bundled Post-op E/M	All related follow-up visits are bundled; no separate billing
Unrelated E/M During Global	Modifier -24; must be clearly documented as unrelated to the eye surgery
Decision for Surgery E/M	Modifier -57 on the E/M code (not the surgical code) when the decision for major surgery is made during an E/M on the day of or day before surgery
Staged Procedure During Global	Modifier -58 — e.g., early socket revision within 90 days of 65105
Unplanned Return to OR (Complication)	Modifier -78 — intraservice work only paid; global period does NOT reset
Unrelated Procedure During Global	Modifier -79 — new global period begins for the unrelated procedure
Transfer of Surgical Care	-54 (surgery only) and -55 (post-op only) for the receiving provider

Key global period insight for 65105: The pegging procedure (65125) is almost never within the 90-day global because fibrovascular ingrowth takes 6-12 months to confirm. Therefore, modifier -58 is rarely needed for 65125 following 65105. The most common reason for a within-global return to OR is implant exposure or wound dehiscence — typically coded with 65155 or a socket repair code with modifier -78 (unplanned complication). Implant exposure rates are generally low (~2-8% for wrapped porous implants) but are higher in previously irradiated orbits or contaminated fields.

Common Modifiers for CPT 65105

Modifier	Name	When to Use with 65105
-RT	Right Side	Procedure on the right eye — always required; claim rejects without laterality
-LT	Left Side	Procedure on the left eye — always required
-50	Bilateral Procedure	Simultaneous bilateral enucleation with muscle-attached implants — rare; 150% payment adjustment; confirm single-line vs. two-line payer preference
-57	Decision for Surgery	Appended to the E/M code (not 65105) when decision for major surgery was made during E/M on the day of or day before surgery
-80	Assistant Surgeon (MD/DO)	Full physician assistant for the entire procedure
-81	Minimum Surgical Assistant	Physician providing partial/minimal assistance
-82	Assistant - No Resident Available	Teaching facility; document resident unavailability
-AS	Non-Physician Assistant at Surgery	PA/NP/CNS assisting; required by Medicare instead of -80
-22	Increased Procedural Services	Substantially increased complexity (prior orbital radiation, dense scarring, prior failed implant, severe infection, unusual anatomy); requires written documentation; 15-30% payment increase if approved
-52	Reduced Services	Procedure partially completed (e.g., globe removed but implant not placed due to intraoperative finding — consider whether 65101 is now the more accurate code)
-53	Discontinued Procedure	Surgery terminated after initiation due to patient safety or anesthetic emergency
-54	Surgical Care Only	Surgeon performs surgery; transfers post-op management
-55	Post-op Management Only	Provider accepting post-op care from transferring surgeon
-58	Staged/Related Procedure During Global	Planned return to OR within 90-day global (e.g., early socket revision; rarely needed for pegging which is typically after the global)
-59	Distinct Procedural Service	Distinct separate same-day service; use only with full documentation when NCCI edit otherwise bundles inappropriately
-62	Two Primary Surgeons	Complex orbital procedure requiring two surgeons with distinct expertise performing separately documentable portions
-73	Discontinued at ASC (Pre-Anesthesia)	Procedure cancelled before anesthesia induction at ASC
-74	Discontinued at ASC (Post-Anesthesia)	Discontinued after anesthesia induction; reduced payment
-78	Unplanned Return to OR (Related)	Complication requiring OR return during global (implant exposure, orbital hemorrhage, wound dehiscence)
-79	Unrelated Procedure During Global	Completely unrelated surgical procedure; new global period
-24	Unrelated E/M During Global	E/M for an unrelated problem during global; must document clearly as unrelated
-GC	Resident Under Teaching Physician	Teaching physician attestation required when resident participates

MS-DRG Mapping (Inpatient Only)

CPT 65105 is predominantly performed as an outpatient procedure (ASC or hospital outpatient). Inpatient admission is appropriate when the underlying condition requires it — intraocular malignancy requiring chemotherapy coordination, pediatric cases, severe orbital infection, or significant systemic comorbidities. 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

Tip

CC/MCC documentation impact: The reimbursement differential between DRG 124 (MCC) and DRG 126 (no CC/MCC) can exceed $6,000-$12,000 depending on the hospital’s wage index. Active malignancy, metastatic disease, panophthalmitis, septicemia, diabetes with complications, or cardiac conditions documented by the physician can elevate the DRG from 126 to 125 or 124. Meticulous physician documentation of all active and relevant comorbidities is essential — query physicians when conditions are mentioned but not formally documented with full specificity.

Important

Malignancy DRG routing: When enucleation is performed for retinoblastoma (C69.2x), uveal melanoma (C69.3x/C69.4x), or other intraocular malignancy in an inpatient setting, the DRG grouper may route to MDC 17 (Hematological/Solid Neoplasms) rather than MDC 02, depending on principal diagnosis sequencing. The principal diagnosis should be the condition established after study to be chiefly responsible for the admission (UHDDS definition). If the admission was primarily for surgical treatment of the malignancy, sequence the malignancy code (C69.xx) first.

ICD-10-PCS Equivalent for Inpatient Coding (65105):

ICD-10-PCS Element	Value
Section	0 - Medical and Surgical
Body System	8 - Eye
Root Operation	T - Resection
Body Part	8 - Eye, Right / 9 - Eye, Left
Approach	0 - Open
Device	J - Synthetic Substitute (synthetic porous implant such as Medpor or bioceramic) OR K - Nonautologous Tissue Substitute (wrapped with donor tissue such as donor sclera or pericardium)
Qualifier	Z - No Qualifier

Notice

65105 vs. 65103 ICD-10-PCS distinction: The muscle attachment technique of 65105 vs. 65103 is not directly captured by a separate ICD-10-PCS code — the distinction is made at the operative report level for physician coding (CPT), while the PCS device character primarily distinguishes implant material type. Facility coders should reference the operative note for device character selection and coordinate with the physician coder to ensure the professional and facility claims are concordant.

Tip

ICD-10-PCS Code Examples:

• Right eye, porous polyethylene implant (synthetic): 08T80JZ
• Left eye, hydroxyapatite wrapped in donor sclera (nonautologous tissue): 08T90KZ

Common Diagnosis Codes Used with CPT 65105

ICD-10-CM Code	Description	Clinical Notes
H44.511	Absolute glaucoma, right eye	Painful blind end-stage eye; most common adult indication; implant with muscle attachment for optimal prosthetic motility
H44.512	Absolute glaucoma, left eye	Same — left eye
H44.513	Absolute glaucoma, bilateral	Use modifier -50; bilateral simultaneous enucleation with implants is rare
H44.521	Atrophy of globe (phthisis bulbi), right eye	Shrunken, disfigured, non-functional eye; 65105 provides best cosmetic outcome
H44.522	Atrophy of globe (phthisis bulbi), left eye	Same — left eye
C69.21	Malignant neoplasm of retina, right eye	Retinoblastoma; most common pediatric primary intraocular malignancy; enucleation is definitive treatment for groups D/E
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; enucleation for large tumors
C69.32	Malignant neoplasm of choroid, left eye	Same — left eye
C69.41	Malignant neoplasm of ciliary body, right eye	Ciliary body melanoma; 65105 with porous implant provides best post-enucleation rehabilitation
C69.42	Malignant neoplasm of ciliary body, left eye	Same — left eye
C69.91	Malignant neoplasm of eye, unspecified, right eye	Pending histology; 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	Traumatic globe rupture; 65105 preferred when socket is clean and primary implant placement is safe
S05.22XA	Same — left eye, initial encounter
H44.131	Sympathetic uveitis, right eye	Inciting injured eye; 65105 with porous implant for optimal long-term socket rehabilitation
H44.132	Sympathetic uveitis, left eye	Same — left eye as inciting eye
H44.121	Parasitic endophthalmitis, unspecified, right eye	When infection resolved; 65105 for definitive management
H44.122	Parasitic endophthalmitis, unspecified, left eye	Same — left eye
Q11.2	Microphthalmos	Congenital; selected cases where the severely underdeveloped eye requires removal with volume replacement
Z90.01	Acquired absence of right eye	Status code; used in post-operative and follow-up records, NOT on the surgical claim
Z90.02	Acquired absence of left eye	Same — left eye; documents prior enucleation in ongoing records

Tip

Coding Tip - Uveal melanoma staging: When coding enucleation for uveal melanoma (C69.3x/C69.4x), additional codes may be appropriate to capture metastatic staging (e.g., C78.xx for hepatic metastasis if present, or Z17.x for receptor status if applicable). Accurate staging documentation supports medical necessity for post-operative surveillance imaging and any systemic therapy.

Tip

Coding Tip - Bilateral retinoblastoma: When bilateral retinoblastoma requires bilateral enucleation in a single session, both C69.21 and C69.22 are reported as co-equal principal and secondary diagnoses. Code both to document the bilateral nature of disease, which has staging and treatment implications.

Coding Examples

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Example 1 - Uveal Melanoma, Right Eye, Porous Hydroxyapatite Implant, Muscles Attached

Clinical Scenario: A 58-year-old male presents with a large choroidal melanoma of the right eye (C69.31), deemed too large for plaque radiotherapy. After oncologic consultation and informed consent, the ophthalmologist performs enucleation of the right eye with insertion of a 20 mm wrapped hydroxyapatite sphere. All four rectus muscles are sutured directly through the donor scleral wrap into the HA implant surface at each cardinal quadrant. The globe is submitted to pathology. An assistant surgeon (fellow ophthalmologist) is present. The operating microscope is used for the muscle attachment suturing.

CPT Coding — Primary Surgeon:

• 65105-RT - Enucleation of eye; with implant, muscles attached to implant (right eye)
• 69990 - Operating microscope (add-on; no modifier -51)

CPT Coding — Assistant Surgeon (separate claim):

• 65105-RT-80 - Same procedure; assistant surgeon modifier

ICD-10-CM:

• C69.31 - Malignant neoplasm of choroid, right eye

Pathology (Pathology Department):

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

Place of Service: 22 (On Campus Outpatient Hospital)

Imaging Plan: MRI orbit with gadolinium (70543) scheduled at 6 months to assess fibrovascular ingrowth into the HA implant prior to pegging consideration. Billed by radiology separately.

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Example 2 - Absolute Glaucoma, Left Eye, Medpor Implant, Outpatient ASC

Clinical Scenario: A 74-year-old female with a painful, blind left eye (H44.512 - absolute glaucoma) has failed all conservative management. She desires the best possible cosmetic outcome and is an appropriate candidate for a porous implant with muscle attachment. The surgeon performs enucleation with insertion of a 22 mm Medpor (porous polyethylene) implant wrapped in polyglactin mesh. All four rectus muscles are sutured directly to the implant surface through the mesh. No operating microscope used.

CPT Coding:

• 65105-LT - Enucleation of eye; with implant, muscles attached to implant (left eye)

ICD-10-CM:

• H44.512 - Absolute glaucoma, left eye

Place of Service: 24 (Ambulatory Surgical Center)

Facility Note: The ASC bills L8610 (Ocular implant) separately for the Medpor sphere; the surgeon does not bill L8610 on the professional fee claim.

Follow-up Plan: At 6-12 months post-operatively, if fibrovascular ingrowth is confirmed, a pegging procedure (65125-LT) may be scheduled at a separate session, billed as a new independent procedure with its own 90-day global period. No modifier -58 needed at that time since it will be well beyond the 90-day global of 65105.

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Example 3 - Retinoblastoma, Left Eye, Pediatric Inpatient, Long Optic Nerve Section

Clinical Scenario: A 4-year-old child has unilateral group E retinoblastoma, left eye (C69.22), refractory to chemotherapy. The pediatric ophthalmologist performs enucleation with a 16 mm hydroxyapatite sphere. All four rectus muscles are sutured to the HA implant through the donor scleral wrap. A long optic nerve segment (~15 mm) is removed to maximize the likelihood of negative surgical margins. The globe and optic nerve are submitted to pathology with a request for intraoperative frozen section of the optic nerve cut end. The child is admitted for general anesthesia monitoring and post-operative chemotherapy coordination.

CPT Coding:

• 65105-LT - Enucleation of eye; with implant, muscles attached to implant (left eye)

ICD-10-CM:

• C69.22 - Malignant neoplasm of retina, left eye (retinoblastoma)

ICD-10-PCS (Inpatient):

• 08T90KZ - Resection of Left Eye, Open approach, Nonautologous Tissue Substitute (donor scleral wrap), No Qualifier

Pathology:

• 88309 - Level VI; eye, enucleated (billed by pathology department)
• 88331 - Frozen section, intraoperative (optic nerve margin; billed by pathology)

Place of Service: 21 (Inpatient Hospital)

MS-DRG Note: Principal diagnosis C69.22 may route to MDC 17 (Solid Neoplasms) rather than MDC 02. Verify DRG assignment with the facility HIM/coding team. Documentation of active chemotherapy, any systemic metastatic staging, and all comorbidities should be captured for accurate CC/MCC assignment and DRG optimization.

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Example 4 - Sympathetic Ophthalmia, Right Eye as Inciting Eye, Urgent Enucleation

Clinical Scenario: A 32-year-old male sustained penetrating trauma to the right eye 4 weeks ago. He now develops early sympathetic uveitis in the left (fellow) eye (H44.131 — right eye is the inciting eye). The ophthalmologist urgently enucleates the right (inciting) eye with a 20 mm bioceramic implant and direct muscle attachment to prevent further antigenic stimulation. The surgeon chooses 65105 to optimize long-term socket rehabilitation with muscle coupling.

CPT Coding:

• 65105-RT - Enucleation of eye; with implant, muscles attached to implant (right eye — the inciting eye)

ICD-10-CM:

• H44.131 - Sympathetic uveitis, right eye (the inciting eye being removed)
• H44.132 - Sympathetic uveitis, left eye (the threatened fellow eye — additional diagnosis)
• S05.21xD - Ocular laceration/rupture with loss of intraocular tissue, right eye, subsequent encounter (original trauma — seventh character D)

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

Critical Documentation Alert: The operative note must explicitly and unambiguously identify:

• The RIGHT eye as the inciting (injured) eye being surgically removed
• The LEFT eye as the threatened fellow eye being protected
• The pre-operative “time-out” verification of correct laterality must be documented
• Wrong-site/wrong-eye surgery in this scenario would be immediately catastrophic and career-ending; laterality documentation cannot be overstated

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Example 5 - Increased Complexity, Prior Orbital Radiation, Right Eye

Clinical Scenario: A 70-year-old female with a history of orbital radiotherapy (50 Gy) for a prior intraocular lymphoma now requires enucleation of the right eye for an absolute glaucoma (H44.511) with intractable pain. The surgeon finds dense radiation-induced orbital fibrosis, obliterated tissue planes, severely scarred Tenon’s capsule, and friable, irradiated conjunctiva. Operative time is substantially longer than typical. A porous polyethylene implant is used with direct muscle attachment despite the increased extrusion risk — surgeon documents the decision and risk discussion with the patient. No clean implant wrap plane is available; a fascia lata graft is harvested from the thigh to wrap the implant.

CPT Coding:

• 65105-RT-22 - Enucleation of eye; with implant, muscles attached (right eye); substantially increased complexity
• 20920-59 - Fascia lata graft; by stripper (if fascia lata harvest is separately documented as a distinct service — verify NCCI edit status and payer policy before billing; -59 modifier required if not bundled; some payers bundle this)

ICD-10-CM:

• H44.511 - Absolute glaucoma, right eye
• Z85.840 - Personal history of malignant neoplasm of eye (prior intraocular lymphoma)
• L57.1 - Actinic reticuloid / radiation dermatitis as applicable, or appropriate late effects of radiation code

Modifier -22 Requirements:

• Attach a written narrative explaining the substantially increased surgical complexity: radiation fibrosis, obliterated tissue planes, friable tissue, fascia lata harvest, increased operative time (document actual vs. typical time)
• Without this supporting documentation, the -22 upcharge will be denied
• Some payers require pre-authorization for modifier -22 — verify before the date of service

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Example 6 - Implant Pegging After 65105 (Planned Staged Procedure, Outside Global)

Clinical Scenario: Ten months after 65105-LT (absolute glaucoma, left eye) with a hydroxyapatite implant, the surgeon orders a gadolinium-enhanced MRI orbit (70543) to assess fibrovascular ingrowth. Radiology confirms complete vascular ingrowth throughout the HA implant. The surgeon discusses pegging with the patient and schedules the motility post placement.

CPT Coding (Pegging Encounter):

• 65125-LT - Modification of ocular implant with placement or replacement of pegs (left eye)

ICD-10-CM:

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

No modifier -58 needed: Ten months is well beyond the 90-day global period of 65105. This is a completely new, independent surgical episode with its own 090-day global period.

Imaging (Radiology Department — billed separately):

• 70543 - MRI orbit without and with contrast (fibrovascular ingrowth assessment; billed by radiology, not surgeon)

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Example 7 - Implant Exposure, Return to OR During Global Period

Clinical Scenario: Five weeks after 65105-RT for retinoblastoma (C69.21), the pediatric patient returns with a 3 mm area of implant exposure through a small area of conjunctival wound dehiscence. The surgeon returns the patient to the OR for conjunctival advancement and repair to cover the exposed implant surface.

CPT Coding:

• 65155-RT-78 - Reinsertion of ocular implant; with or without conjunctival graft (right eye; modifier -78 = unplanned return to OR during global period for related complication)

ICD-10-CM:

• T85.318A - Breakdown (mechanical) of other ocular prosthetic devices, implants and grafts, initial encounter
• C69.21 - Malignant neoplasm of retina, right eye (underlying diagnosis)

Modifier -78 Payment Impact: CMS pays only the intraservice work component (intra-operative percentage of the allowed amount) when modifier -78 is used — the pre-operative and post-operative components are already included in the original 65105 global and are not separately paid. The global period of 65105 does not restart or extend with a -78 procedure; it continues from the original 65105 operative date.

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Example 8 - Bilateral Enucleation, Bilateral Retinoblastoma

Clinical Scenario: A 2-year-old child with bilateral group D/E retinoblastoma (C69.21 right; C69.22 left) requires bilateral enucleation in a single operative session. Both eyes are enucleated with porous HA implants and direct muscle attachment bilaterally.

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

• 65105-50 - Bilateral; single line item with modifier -50; 150% payment adjustment

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

• 65105-RT - Right eye
• 65105-LT-51 - Left eye; multiple procedure reduction modifier

ICD-10-CM:

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

Tip

Verify the specific payer’s bilateral billing preference before submission. Incorrect bilateral formatting for a given payer results in either a denial or an overpayment requiring refund.

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Surgical Documentation Requirements

To support medical necessity for CPT 65105 and specifically defend the muscle-attached code selection over 65103, the operative note and pre-operative record must include:

Pre-operative documentation:

• Documented diagnosis with no useful visual potential (VA: NLP; or documented visual prognosis with clinical findings)
• Specific indication: pain, malignancy, trauma, sympathetic ophthalmia, cosmesis
• Evidence of failed conservative management
• Informed consent including: enucleation vs. evisceration decision; muscle-attached vs. muscle-unattached implant; porous vs. non-porous implant selection; risks of extrusion, infection, implant migration; pegging discussion
• Pre-operative A-scan biometry of the contralateral eye for implant size selection (document axial length and planned implant diameter)
• For malignancy: tumor board documentation, pre-operative imaging report confirming tumor extent

Operative note MUST explicitly state:

• Procedure: “enucleation of the [right/left] eye with primary orbital implant insertion, muscles attached to implant”
• All six muscles identified, isolated, disinserted, and tagged
• Optic nerve transected with [scissors/snare]; estimated length of nerve removed: ~[x] mm
• Globe delivered intact; submitted to pathology: [yes/no]
• Implant: type (HA/Medpor/bioceramic), manufacturer if relevant, size in mm
• Wrap material: [donor sclera/processed pericardium/polyglactin mesh/fascia lata/other]
• Muscle attachment statement (CRITICAL for 65105 vs. 65103): “The [medial/lateral/superior/inferior] rectus muscles were sutured directly to the [implant surface/wrap in-to-implant] using [suture type, e.g., 5-0 Vicryl] at the [corresponding quadrant positions]” — this explicit language is the key documentation distinction
• Oblique muscle management (attached/allowed to fall/sutured to wrap)
• Anterior Tenon’s capsule closure technique and suture material
• Conjunctival closure
• Conformer size and placement
• Hemostasis and EBL

Post-operative documentation:

• Each post-op visit: “post-operative visit following 65105-[RT/LT] performed on [date]”
• Socket healing progress, conformer status, implant palpation status (no exposure)
• Plans for prosthetic fitting referral
• Discussion of pegging timeline and fibrovascular ingrowth imaging plans
• Any complications explicitly linked (or separated from) the 65105 procedure for accurate modifier application

NCCI Edit Awareness

Edit Relationship	Action Required
65105 + 65101 (same eye, same session)	Mutually exclusive — use only one; 65101 = no implant
65105 + 65103 (same eye, same session)	Mutually exclusive — the muscle attachment technique determines the correct code; never bill both
65105 + 65091/65093 (same eye)	Mutually exclusive — evisceration and enucleation are distinct procedures
65105 + 65110-65114 (same session)	Mutually exclusive — exenteration is a distinct, more extensive procedure
65105 + 65140 (same session)	Edit applies — 65140 is a secondary implant code; if implant placed at same enucleation session with muscle attachment, use 65105 only
65105 + conjunctival repair (65270-65286)	May be bundled; use modifier -59 only with documentation of a clearly distinct, separately identifiable repair for a separate indication
65105 + 20920 (fascia lata graft)	May or may not be bundled depending on payer and edit version — review current NCCI PTP edit table; if not bundled, use -59 with full documentation
MUE = 1 per day per eye	Only one unit of 65105 per eye per operative session; any claim for multiple units will deny
69990 with 65105	Add-on code — do NOT apply modifier -51; no laterality modifier required on 69990; report separately when the operating microscope is documented as used