Surgical · Other

Secondary revision of a prior orbitocraniofacial reconstruction, addressing residual or recurrent deformities of the orbital and craniofacial skeleton.

Verified May 8, 2026 · 5 sources ↓

Medicare: $764.21
Work RVU: 11.47
Global, days: 90
Region: Other

Drawn from CMSAAPCVaAtriohp

Documentation requirements

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

Source · Editorial brief grounded in 5 cited references ↓

Identify the index procedure: name, date, and what was reconstructed in the original surgery.
Describe the specific deformity being revised — orbital volume deficit, enophthalmos measurement, asymmetry with functional impact, or structural failure of prior repair.
State the functional impairment driving the revision (e.g., diplopia, impaired extraocular movement, vision compromise, or airway/structural concern).
Operative note must name the specific bones and structures addressed — orbital rim, orbital floor, lateral wall, cranial base — not generic 'orbitocraniofacial structures'.
Document implant or graft type and source if bone grafting or alloplastic material is used.
Include pre-op imaging (CT with fine cuts through orbits) confirming structural abnormality requiring revision.
Note any prior surgical history relevant to the reconstruction, including prior hardware, grafts, or failed repairs.

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 62 Co-surgeons 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 5 cited references ↓

CPT 21275 covers a secondary (i.e., repeat or staged) revision of a previously performed orbitocraniofacial reconstruction. The procedure addresses persistent or newly developed deformities of the orbital rims, periorbital skeleton, or adjacent craniofacial bones — most commonly sequelae of trauma, congenital craniofacial anomalies, or incomplete correction from the index procedure. It is by definition a re-operative case, which distinguishes it from primary orbital reconstruction codes.

The 90-day global period means all routine post-op care from the day before surgery through day 90 is bundled into the payment. If a complication requires an unplanned return to the OR for a related problem during that window, append modifier 78. An unrelated OR procedure in the same global period takes modifier 79. A new E/M during the global for an unrelated condition requires modifier 24.

Prior authorization is common for this code given the high facility payment and its classification as a complex reconstructive procedure. Payer policies vary significantly on what constitutes medical necessity for a secondary revision versus cosmetic refinement — document the functional deficit (vision, orbital volume, enophthalmos measurement) explicitly, not just aesthetic asymmetry.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU vs. total RVU

The work RVU (11.47) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (22.88) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	11.47
Practice expense RVU	9.28
Malpractice RVU	2.13
Total RVU	22.88
Medicare national rate	$764.21
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	$764.21
HOPD (APC 5165) Hospital outpatient department	$6,048.05
ASC (PI J8) Ambulatory surgical center (freestanding)	$3,843.65

Common denial reasons

The recurring reasons claims for CPT 21275 get rejected.

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

Cosmetic vs. reconstructive distinction not supported — documentation lacks a stated functional deficit or objective measurement (e.g., enophthalmos in mm).
Prior authorization not obtained before the procedure; this code routinely triggers PA requirements at commercial and Medicare Advantage plans.
Global period conflict — billed during the 90-day global of a related prior procedure without modifier 78 or 79.
Insufficient documentation of prior surgery — payers deny secondary revision claims when the index procedure and its outcome are not clearly established in the record.
Unbundling flag — separately billing bone graft harvest or fixation hardware when those services are considered inclusive to the revision procedure.

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 5 cited references ↓

01What makes 21275 a 'secondary' revision — does the prior surgery have to be a specific code?

The prior surgery must have been an orbitocraniofacial reconstruction, but no specific code is required. Document the date, type, and outcome of the index procedure. The key is establishing that this is a re-operative case addressing incomplete correction or a new deformity at the same anatomic site.

02Can 21275 be billed with orbital floor repair codes on the same date?

Potentially yes, with modifier 51, if distinctly separate structures are addressed and the additional procedure goes beyond the scope of the revision. NCCI PTP edits apply — check the current edit table before billing multiple craniofacial codes same-day, and document each procedure's anatomic site separately in the operative note.

03Does the 90-day global period apply to the original reconstruction or to 21275 itself?

Each surgery carries its own global period. The 90-day global attached to 21275 starts on the day of the revision. Separately, if you're billing 21275 within the global period of the index reconstruction, you need modifier 58 (staged/planned) or 78 (unplanned, related return to OR).

04What ICD-10 diagnosis codes are typically used with 21275?

Common diagnoses include enophthalmos (H05.40–H05.42), orbital deformity (H05.30–H05.32), late effects of facial fracture (M96-range or sequela codes), and congenital craniofacial anomaly codes depending on the underlying condition. Payers match the diagnosis to the functional indication — cosmetic asymmetry alone without a functional ICD-10 code will drive denial.

05Is prior authorization universally required for 21275?

Not universally, but most commercial insurers and Medicare Advantage plans require it given the procedure's complexity and facility cost. Original Medicare (Parts A/B) does not require PA, but medical necessity review on post-payment audit is common. Verify PA requirements with each payer before scheduling.

06How should modifier 22 be used with 21275?

Use modifier 22 when the work significantly exceeds a typical secondary revision — for example, extensive scarring from prior surgery, failed implant removal with complex reconstruction, or combined intracranial and extracranial approach. Attach a cover letter quantifying the additional operative time and complexity. Without that letter, payers will ignore the modifier.

Sources & references

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

Mira Scribe

Mira's AI scribe captures the critical revision-specific elements from dictation: name and date of the index reconstruction, the structural deformity being corrected, functional deficits present (enophthalmos measurement, diplopia, extraocular movement restriction), specific bones and walls addressed intraoperatively, and graft or implant details. This prevents the most common denial — a claim that reads as cosmetic refinement rather than medically necessary secondary reconstruction.

See how Mira captures CPT 21275 documentation