Open surgical reduction of a nasoethmoid complex fracture without internal fixation hardware placement.

Verified May 8, 2026 · 6 sources ↓

Medicare: $626.93
Work RVU: 6.7
Global, days: 90
Region: Other

Drawn from CMSAaomsAAPCMdclarityFindacode

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Operative note must name the specific approach used to access the nasoethmoid complex — audit teams flag notes that reference only 'open approach' without anatomical detail.
Confirm and document the absence of internal fixation; if plates or screws were placed intraoperatively, the claim shifts to 21339.
Preoperative imaging (CT) referenced in the operative note to support medical necessity of open versus closed reduction.
Fracture laterality, displacement degree, and comminution documented to justify open treatment selection.
For same-day E/M billed with modifier 57, the note must explicitly record the decision for surgery as occurring during that encounter.
When concurrent facial fractures are repaired, each fracture site and its treatment must be documented separately to support unbundling with modifier 59 or XS.

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 25 Significant separate E/M 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 57 Decision for surgery 59 Distinct service 62 Co-surgeons LT Left side RT Right side XS Separate structure

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 21338 covers open treatment of a nasoethmoid fracture — the complex involving the nasal bones and ethmoid — when the surgeon achieves reduction through an open approach but does not apply internal fixation. This distinguishes it from 21339 (with fixation) and from closed nasal fracture codes in the 21310–21335 range. The nasoethmoid complex sits at the junction of the midface and skull base, and open access is required when closed manipulation cannot restore alignment.

The 90-day global period means all routine post-op care through day 90 is bundled into the payment. Same-day E/M visits billed for a separate, unrelated condition require modifier 25; if the E/M visit was the decision point for surgery, append modifier 57 to the E/M code — not to 21338 itself. When concurrent facial fractures (orbital, frontal sinus, malar) are also repaired in the same session, each component is reported separately to the extent NCCI edits allow; modifier 59 or an XS modifier can override applicable bundling edits when clinical documentation confirms anatomically distinct procedures.

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 (6.7) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (18.77) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	6.7
Practice expense RVU	11.08
Malpractice RVU	0.99
Total RVU	18.77
Medicare national rate	$626.93
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	$626.93
HOPD (APC 5165) Hospital outpatient department	$6,048.05
ASC (PI A2) Ambulatory surgical center (freestanding)	$3,025.62

Common denial reasons

The recurring reasons claims for CPT 21338 get rejected.

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

Operative note lacks documentation confirming no fixation was used, causing payers to question whether 21338 or 21339 was the correct code.
Same-day E/M denied for missing modifier 25 or 57 — payers bundle the evaluation into the surgical global when the modifier is absent.
Concurrent facial fracture codes denied as bundled without modifier 59 or XS and supporting documentation of anatomically distinct repair sites.
Medical necessity denial when preoperative imaging is not referenced or attached, leaving the choice of open over closed reduction unsupported.
Modifier 52 omitted on bilateral fracture cases where interdental fixation was indicated by the code but only partially applied.

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01What is the difference between CPT 21338 and 21339?

21338 is open treatment without fixation; 21339 is open treatment with fixation. If the surgeon places any plates, screws, or wires to stabilize the nasoethmoid complex, bill 21339 — not 21338.

02Can 21338 be billed with other facial fracture codes in the same session?

Yes. Each distinct facial fracture repair (orbital, frontal sinus, malar, Le Fort) is reported separately. NCCI edits may bundle certain pairs; modifier 59 or XS with documentation of anatomically distinct sites overrides those edits when clinically supported.

03Does the 90-day global period affect post-op visits for this code?

Yes. All routine post-op visits through day 90 are bundled. Bill unrelated conditions with modifier 24 on the E/M code. Bill a new, unrelated surgical procedure performed within the global with modifier 79.

04When should modifier 57 be used with 21338?

Append modifier 57 to the E/M code — not to 21338 — when the decision to perform this open nasoethmoid repair was made during that same-day evaluation. This applies because 21338 carries a 90-day global, making it a major surgical procedure under CMS rules.

05Is modifier 50 appropriate for bilateral nasoethmoid fractures?

It can be, but confirm with the specific payer first. Medicare and many commercial plans apply bilateral payment adjustments differently. Some payers prefer LT/RT on separate lines over modifier 50 on a single line.

06When is modifier 22 justified for 21338?

Use modifier 22 when documented complexity — severe comminution, significant anatomical distortion, or unusual operative time — required substantially more work than the standard procedure. Attach a cover letter summarizing the additional effort; otherwise expect denial or downcoding.

07Can two surgeons bill 21338 with modifier 62?

Yes, if the complexity of the nasoethmoid repair genuinely required two co-surgeons operating simultaneously. Each surgeon bills 21338-62 with operative notes defining their individual role. Many payers require pre-authorization and supporting documentation for co-surgeon billing.

Sources & references

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

Mira Scribe

Mira's AI scribe captures the surgical approach name, explicit confirmation that no internal fixation was placed, preoperative imaging findings referenced intraoperatively, and fracture characteristics (displacement, comminution, laterality) from dictation. For concurrent facial fracture repairs, it flags each distinct anatomic site treated so modifier 59 or XS is applied to the correct line items — preventing blanket bundling denials at claims submission.

See how Mira captures CPT 21338 documentation