Surgical · Other

Unilateral orbital repositioning via periorbital osteotomies with bone grafting, performed through an extracranial approach only — no intracranial entry.

Verified May 8, 2026 · 8 sources ↓

Medicare: $1,466.63
Total RVUs: 43.91
Global, days: 90
Region: Other

Drawn from CMSEmednyMdclarityAAPCAao

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 8 cited references ↓

Specify the approach explicitly as extracranial — distinguish from combined intra/extracranial approach used for 21267 vs. 21268 selection
Document the laterality (left or right orbit) and confirm procedure is unilateral
Identify the underlying diagnosis and functional impairment — congenital deformity, post-traumatic malposition, or failed prior reconstruction — to establish reconstructive (not cosmetic) medical necessity
Document bone graft source: autograft harvest site, allograft, or other material, and note if harvest was performed during same operative session
Operative note must name the specific osteotomies performed and describe how the orbit was repositioned — 'standard craniofacial approach' language alone will trigger audit flags
Confirm no intracranial entry occurred; if cranial access was required, 21268 is the correct code

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 51 Multiple procedures 52 Reduced services 57 Decision for surgery 58 Staged or related 59 Distinct service 62 Co-surgeons 74 Discontinued post-anesthesia 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 8 cited references ↓

CPT 21267 describes a unilateral procedure in which the surgeon repositions the bony orbit through periorbital osteotomies confined to an extracranial approach. Bone grafts — which may be autografts harvested during the same session — are applied to stabilize the repositioned orbit. The procedure addresses orbital malposition caused by congenital craniofacial deformities, prior trauma, or failed prior reconstruction. The extracranial-only approach distinguishes 21267 from its companion code 21268, which adds an intracranial component; select the code that matches the operative approach documented in the note.

The 90-day global period covers all routine post-op care through day 90. Separate E/M visits within that window require modifier 24 (unrelated) or 25 (significant, separately identifiable on the same day as a procedure). Because this is a unilateral code by descriptor, billing the contralateral orbit requires a separate line with modifier 59 or LT/RT modifiers — not modifier 50, which applies to procedures performed bilaterally in the same session under a bilateral-indicator-eligible code.

Payers routinely scrutinize this code for cosmetic versus reconstructive intent. The operative note and supporting clinical documentation must establish medical necessity — documenting the underlying diagnosis (e.g., orbital hypertelorism, post-traumatic deformity, congenital anomaly) and functional impairment. Absent that linkage, expect a cosmetic-exclusion denial regardless of the complexity of the surgery performed.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	20.17
Practice expense RVU	19.99
Malpractice RVU	3.75
Total RVU	43.91
Medicare national rate	$1,466.63
Global period	90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$1,466.63
HOPD (APC 5165) Hospital outpatient department	$6,048.05
ASC (PI J8) Ambulatory surgical center (freestanding)	$5,082.31

Common denial reasons

The recurring reasons claims for CPT 21267 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Cosmetic exclusion: payer denies for lack of documented functional impairment or reconstructive indication — submit clinical records showing diagnosis and functional deficit
Wrong code selected: 21268 billed when operative note documents extracranial-only access, or vice versa — approach must match the code descriptor
Missing or vague diagnosis linkage: ICD-10 code submitted does not support orbital repositioning as medically necessary (e.g., cosmetic-sounding diagnosis without supporting clinical context)
Bone graft not separately documented: payer disputes that autograft harvest occurred during the same session without explicit documentation of harvest site and technique
Bilateral modifier misuse: modifier 50 appended to a unilateral-descriptor code — use RT/LT or modifier 59 on a second line for contralateral procedures

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 8 cited references ↓

01What distinguishes 21267 from 21268?

Approach. CPT 21267 is extracranial only — the surgeon never enters the skull. CPT 21268 adds an intracranial component. The operative note must explicitly state which access was used; coders should not infer approach from diagnosis alone.

02Is 21267 considered a cosmetic procedure by Medicare?

Not automatically. Medicare and most payers cover it when performed for reconstructive indications — post-traumatic orbital deformity, congenital anomalies with documented functional impairment, or correction of prior failed reconstruction. Submit supporting ICD-10 codes and clinical documentation to overcome cosmetic-exclusion edits.

03Can bone graft harvest be billed separately with 21267?

The bone graft harvest is included in the 21267 descriptor when autograft is obtained during the same session — it is not separately reportable. Document the harvest site anyway; auditors look for it to confirm the work was actually performed.

04How do you bill if both orbits are repositioned in the same session?

21267 is a unilateral code by descriptor. Bill a second unit on a separate line with modifier LT or RT (and modifier 59 if needed to bypass a bundling edit). Do not use modifier 50, which applies to bilateral-indicator-eligible codes — confirm the bilateral indicator for 21267 in the CMS Physician Fee Schedule before using modifier 50.

05What global period applies and what does it cover?

21267 carries a 90-day global period. That includes the day before surgery, the procedure day, and all routine post-op care through day 90. Bill unrelated E/M visits with modifier 24, and same-day significant E/M visits with modifier 25.

06When is modifier 22 appropriate for 21267?

Use modifier 22 when the procedure is substantially more work than typical — for example, severe post-traumatic distortion requiring extended osteotomy time or unusually complex graft fixation. Document the increased complexity in the operative note with estimated additional time and rationale; payers will request records before paying the upcharge.

07Is prior authorization typically required for 21267?

Most commercial payers require prior authorization for 21267 given its high RVU value and cosmetic-exclusion risk. Confirm payer-specific PA requirements before scheduling. Medicare does not require PA for physician fee schedule services, but LCD coverage criteria still apply.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures the surgical approach (extracranial only vs. combined), laterality, specific osteotomy technique, orbital repositioning method, and bone graft details — including harvest site — directly from dictation. This prevents the most common audit flag for 21267: an operative note that confirms osteotomies were performed but omits approach type, forcing a coder to guess between 21267 and 21268, and the most common denial: no documented link between the diagnosis and reconstructive medical necessity.

See how Mira captures CPT 21267 documentation