Open repair of an orbital floor blowout fracture using a periorbital (around-the-eye) incision approach, without implant or bone graft.

Verified May 8, 2026 · 6 sources ↓

Medicare: $630.94
Work RVU: 9.33
Global, days: 90
Region: Other

Drawn from CMSAaoAAOSMdclarityFindacode

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Specify the surgical approach by name — periorbital — in the operative note; generic 'standard approach' language flags audits.
Document that no alloplastic implant and no bone graft were placed; their presence moves the case to 21390 or 21395.
Record laterality explicitly (left vs. right orbit) in both the operative report and the diagnosis coding.
Confirm blowout fracture type — orbital floor — distinguished from other orbital fractures billed under 21406–21408.
Document intraoperative findings, including fragment displacement, herniated orbital contents if present, and restoration of orbital floor continuity.
If modifier 22 is appended, the operative note must describe the specific factors — scarring, prior surgery, anatomic complexity — that made work substantially greater than usual.

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 24 Unrelated E/M during global 25 Significant separate E/M 51 Multiple procedures 52 Reduced services 57 Decision for surgery 58 Staged or related 59 Distinct service 62 Co-surgeons 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon AS PA/NP/CNS assistant LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 21386 covers open treatment of an orbital floor blowout fracture accessed through a periorbital incision. The surgeon exposes the fractured orbital floor, repositions displaced bone fragments, and closes the defect without placing an alloplastic implant or harvesting a bone graft — those steps push the case to 21390 or 21395, respectively. The periorbital approach distinguishes this code from its siblings: 21385 uses a transantral (Caldwell-Luc) approach, 21387 uses a combined approach, and 21386 sits specifically in the periorbital-only, no-implant, no-graft tier.

The 90-day global period means all routine post-op care — wound checks, suture removal, follow-up imaging review tied to the operative eye — is bundled through day 90. Unrelated E&M services in that window require modifier 24. If the decision for this surgery was made at an E&M the same day or the day before, append modifier 57 to that E&M, not to 21386 itself.

This code sits in the musculoskeletal surgery section of CPT, billed primarily from inpatient or on-campus outpatient hospital settings. Maxillofacial surgeons and ophthalmologists with orbital surgery privileges are the typical billing providers. Because the orbital floor is a paired structure, laterality modifiers LT and RT are standard — omitting them is a routine claim rejection trigger.

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 (9.33) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (18.89) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	9.33
Practice expense RVU	7.83
Malpractice RVU	1.73
Total RVU	18.89
Medicare national rate	$630.94
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	$630.94
HOPD (APC 5165) Hospital outpatient department	$6,048.05
ASC (PI G2) Ambulatory surgical center (freestanding)	$3,025.62

Common denial reasons

The recurring reasons claims for CPT 21386 get rejected.

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

Missing or ambiguous laterality — claims submitted without LT or RT are routinely rejected by facility and commercial payers.
Upcoding to 21390 or 21395 without documentation of implant placement or bone graft harvest.
E&M billed same-day without modifier 25 or 57, triggering global period bundling denial.
Diagnosis code mismatch — ICD-10 must reflect orbital floor fracture (S02.3-series), not a generic orbital or facial fracture.
Prior authorization not obtained; orbital blowout repair is a scheduled surgical procedure that many commercial payers require pre-auth for.

Frequently asked questions

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

01What separates CPT 21386 from 21390 and 21395?

Approach and materials. 21386 is periorbital approach, no implant, no graft. Add an alloplastic or other implant and you're at 21390. Add a bone graft (including harvest) and you're at 21395. Document what was and wasn't placed.

02Do I need LT or RT on every 21386 claim?

Yes. The orbital floor is a paired anatomical structure. Most facility and commercial payers require laterality modifiers. Omitting LT or RT is one of the most frequent clean-claim failures on this code.

03Can I bill an E&M on the same day as 21386?

Only if it's significant and separately identifiable. Use modifier 25 on the E&M if the visit addressed a problem beyond the pre-op assessment. If the E&M is where the surgical decision was made (day of or day before), use modifier 57 on that E&M instead.

04What global period applies, and what does it cover?

21386 carries a 90-day global. That includes the day-before visit, the surgery day, and all routine post-op care through day 90. Unrelated procedures or E&M services in that window need modifier 79 or 24, respectively.

05When is modifier 62 appropriate for this procedure?

When a maxillofacial surgeon and an ophthalmologist each perform distinct portions of the operation as co-primary surgeons. Both providers append modifier 62 and document their individual operative contributions. This is not the same as an assistant surgeon, which uses modifier 80.

06How does 21386 differ from 21387?

21387 is the combined approach — it uses both a periorbital and a transantral (Caldwell-Luc) route in the same operative session. If only a periorbital incision was made, 21386 is correct. Billing 21387 without documentation of both access points is an upcoding risk.

07Is prior authorization typically required for 21386?

Many commercial payers require pre-authorization for scheduled open orbital fracture repair. Urgent or emergent cases may qualify for expedited review. Confirm with the specific payer before the case — denial on auth grounds is common when the case is booked electively without prior approval.

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 (periorbital), confirmation that no implant or bone graft was used, laterality, and intraoperative findings including fragment displacement and orbital floor restoration. That structured capture prevents the two most common audit flags on this code: missing laterality and undocumented implant/graft absence that would otherwise support a higher-tier sibling code.

See how Mira captures CPT 21386 documentation