CPT 65091 Reimbursement & Benchmarks | OpenPayer

Summary & Overview

CPT 65091: Sclera-Sparing Removal of Intraocular Contents

CPT code 65091 denotes a sclera-sparing removal of the internal contents of a diseased or damaged eye without placement of an implant. This ophthalmic surgical code is used when intraocular tissue is excised but the eye’s outer shell and attached muscles are left intact, distinguishing it from enucleation with implant or evisceration with prosthetic insertion. Nationally, accurate use of this code matters for clinical documentation, surgical quality measurement, and correct claims adjudication for complex ophthalmic procedures.

Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise clinical description, typical sites of service, common payer coverage considerations, and how 65091 fits into the broader set of ophthalmic surgical codes. The publication highlights billing and coding nuances relevant to procedure selection and claim reporting, presents benchmarks where available, and summarizes recent policy or coverage updates affecting ophthalmic surgical reimbursement. Clinical context clarifies when this procedure is appropriate compared with related ocular surgeries, while the billing-focused sections outline documentation elements that support correct coding. Data not available in the input is noted where applicable.

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Billing Code Overview

CPT code 65091 describes a surgical procedure in which the surgeon removes the internal contents of a diseased or damaged eye while preserving the sclera (the eye’s fibrous outer covering) and the extraocular muscles attached to it. The procedure explicitly excludes insertion of an orbital or ocular implant to replace the removed intraocular contents.

Service type: Operative ophthalmology — removal of intraocular contents without orbital implant placement
Typical site of service: Hospital operating room or ambulatory surgery center for ophthalmic surgery

Clinical & Coding Specifications

Clinical Context

A typical patient is an adult with a painful, blind, or severely diseased eye scheduled for a subtotal (internally) evisceration procedure (65091) performed to control infection, relieve pain, or prepare the socket for a future ocular prosthesis. The patient often presents after failed conservative management for endophthalmitis, phthisis bulbi, severe ocular trauma with intraocular damage, or chronic painful blind eye. Preoperative workup includes history, visual acuity (often no light perception), ocular examination, ocular imaging as indicated, and informed consent discussing removal of intraocular contents while preserving the scleral shell and extraocular muscles. The procedure is typically performed in an ambulatory surgical center or hospital operating room under monitored anesthesia care or general anesthesia.

Perioperative workflow: preop verification and medical clearance, marking laterality, antibiotics as indicated, administration of anesthesia, removal of intraocular contents through a small corneal or scleral incision leaving the scleral shell and attached rectus muscles intact, hemostasis, placement of a conformer or temporary dressing rather than an intraorbital implant (no implant insertion per 65091), postoperative pain control and antibiotic regimen, discharge with ophthalmic follow-up for socket care and planning for prosthesis fitting. Common payors for authorization and billing review include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, BUCA, and Medicare.

Coding Specifications

Modifier	Description	When to Use

CPT 65101: Enucleation of Eye, Globe Removed Intact

CPT-65103-ENUCLEATION-WITH-IMPLANT-NO-MUSCLE-ATTACHMENT

CPT 65103: Enucleation with Ocular Implant, No Muscle Attachment

CPT-65105-ENUCLEATION-WITH-OCULAR-IMPLANT-AND-MUSCLE-ATTACHMENT

CPT 65105: Enucleation with Ocular Implant and Muscle Attachment

CPT-65114-ORBITAL-CONTENT-REMOVAL-WITH-MUSCLE-REARRANGEMENT

CPT 65114: Orbital Content Removal with Local Muscle Reconstruction

CPT-65093-ENUCLEATION-INTERNAL-CONTENTS-WITH-OCULAR-IMPLANT

CPT 65093: Removal of Intraocular Contents with Ocular Implantation

CPT-65112-ORBITAL-CONTENT-REMOVAL-EXENTERATION

CPT 65112: Removal of Orbital Contents, Unilateral

CPT-65110-ORBITAL-EXENTERATION-UNILATERAL

CPT 65110: Unilateral Orbital Exenteration, Removal of Orbital Contents

Taxonomy Code	Specialty	Notes
`207W00000X`	Ophthalmology	Ophthalmic surgeons who perform ocular evisceration and related anterior segment procedures.
`207WI0400X`	Oculoplastic Surgery	Specialists in orbital and eyelid surgery often manage socket reconstruction and prosthetic planning.
`2083P0200X`	General Surgery	Occasionally involved in trauma cases with multidisciplinary management, though uncommon for primary evisceration.
`363L00000X`	Optometry	Provides pre- and postoperative ocular surface and prosthetic rehabilitation coordination.
`2080P0000X`	Plastic Surgery	Involvement when complex orbital or facial reconstruction accompanies ocular removal.

Related Diagnoses

ICD-10 Code	Description	Clinical Relevance
`H44.1`	Endophthalmitis	Severe intraocular infection often leading to removal of intraocular contents to control infection and pain.
`H56.8`	Other specified disorders of vision	May include severe painful blind eye conditions prompting evisceration when vision cannot be restored.
`H11.39`	Other pthisis bulbi	A shrunken, non-functional painful eye frequently treated with evisceration for comfort and socket preparation.
`S05.9`	Unspecified injury of eye and orbit	Significant traumatic intraocular injury that can lead to evisceration when globe salvage is not possible.
`C69.9`	Malignant neoplasm of eye, unspecified	In select malignant intraocular tumors with indication to remove intraocular contents while preserving sclera and muscles, though enucleation or exenteration may be preferred depending on spread.

Related CPT Codes

CPT Code	Description	Relationship to This Procedure
`65101`	Enucleation of eye; without orbital implant	Alternative removal procedure when the entire globe including sclera is removed; may be chosen instead of `65091` depending on pathology or surgeon preference.
`65105`	Enucleation of eye; with insertion of orbital implant	Performed when globe removal includes implant placement; contrasts with `65091` which specifies no implant insertion.
`65222`	Repair of socket, conjunctiva and/or Tenon’s capsule; secondary	May be performed after `65091` for socket reconstruction or revision prior to prosthesis fitting.
`68230`	Exenteration, orbital (may include removal of eyelids, cheek)	More extensive procedure for malignant or extensive orbital disease; considered when disease extends beyond globe and sclera.
`92350`	Fitting of ocular prosthesis; initial fitting	Performed during the rehabilitative phase after healing from `65091` when a custom prosthesis is fitted.
`99100`	Anesthesia for patient of extreme age, under 1 year or over 70 years, requiring specific billing (example)	Anesthesia codes or modifiers are commonly associated; anesthesia services are integral to `65091` but are billed separately under anesthesia CPTs.

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