Open surgical repair of an orbital fracture using a combined approach, accessing the orbit through multiple incisions to reconstruct the bony orbit around the eye.

Verified May 8, 2026 · 6 sources ↓

Medicare: $702.09
Work RVU: 9.86
Global, days: 90
Region: Other

Drawn from CMSBedrockbillingCgsmedicareAAPCFindacode

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Identify the specific combined approach by name (e.g., transconjunctival plus subciliary, lower lid plus transoral) — notes that say 'standard approach' are an audit flag.
Document mechanism and nature of injury confirming blowout or complex orbital floor fracture requiring open repair.
Describe all incision sites made and the anatomical structures accessed through each approach.
Record fixation method used: type, size, and placement of plates, screws, mesh, or other implants.
Note pre-operative imaging (CT orbit) confirming fracture pattern and indicating need for combined approach versus single-access repair.
If concurrent facial fractures were also repaired, document each fracture site, repair method, and medical necessity separately to support additional codes.

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 58 Staged or related 59 Distinct service 62 Co-surgeons 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon LT Left side RT Right side XS Separate structure

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 21387 covers open treatment of an orbital floor blowout fracture via a combined surgical approach — meaning the surgeon uses more than one access point (e.g., transconjunctival plus subciliary, or lower lid plus transoral) to fully expose, reduce, and stabilize the fractured orbital bones. This is distinct from single-approach orbital floor repair and is selected when fracture complexity or extent demands multi-vector visualization and fixation. Internal fixation with plates, screws, or mesh implants is typically involved.

The 90-day global period applies. All routine post-op management, including wound checks and implant monitoring visits, is bundled. Unrelated E/M services during the global window require modifier 24; a significant, separately identifiable E/M on the day of surgery requires modifier 25 appended to the E/M, not the surgical code.

This code is used almost exclusively in craniofacial, oromaxillofacial, and plastic surgery settings. When a zygomatic fracture is repaired in the same session, carefully evaluate whether a separate code (e.g., 21356 or 21365) is supported — NCCI edits and the principle that only one fracture repair code per fracture site is reportable apply. Interdental wiring performed as part of the same facial procedure is not separately billable per NCCI Chapter 4 policy.

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 (9.86) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (21.02) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	9.86
Practice expense RVU	9.33
Malpractice RVU	1.83
Total RVU	21.02
Medicare national rate	$702.09
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	$702.09
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 21387 get rejected.

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

Operative note fails to document use of a combined approach — payers downcode to a single-approach orbital repair code.
Missing pre-operative CT imaging in the record to support medical necessity of open repair.
Bundling denial when 21387 is billed same-day with another facial fracture repair code without adequate documentation that separate, distinct fracture sites were treated.
Modifier 51 not appended when billing 21387 as a secondary procedure in a multi-procedure session, triggering multiple-procedure payment reduction issues.
Routine post-op E/M visits billed during the 90-day global period without modifier 24, causing denial of the office visit.

Frequently asked questions

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

01What makes 21387 a 'combined approach' versus a single-approach orbital repair?

Combined approach means the surgeon used two or more distinct incision sites to access and repair the orbit — for example, a transconjunctival incision plus a transoral or subciliary incision. A single lower-lid or transconjunctival incision alone does not support 21387.

02Can I bill a zygomatic fracture repair code with 21387 on the same claim?

Only if the zygomatic fracture is a distinct fracture site with its own documented repair. NCCI policy allows only one fracture repair code per fracture site. If the zygomatic arch is fractured as part of the same orbital complex injury, you need strong documentation of separate repair to support both codes, and modifier 59 or XS will likely be required.

03Does 21387 include the cost of implants like mesh or titanium plates?

Under the physician fee schedule, implant costs are not bundled into the RVU — they are separately billable by the facility. On the facility side, the implant is a passthrough or supply cost. The surgeon's professional component does not include implant billing.

04Is interdental wiring separately billable when performed alongside 21387?

No. Per CMS NCCI Chapter 4, interdental wiring performed as part of a facial fracture repair procedure is not separately reportable. It is only separately billable when performed for a reason completely unrelated to the orbital or facial repair.

05What modifier do I use if a planned second-stage orbital procedure is needed during the 90-day global?

Use modifier 58 for a staged or related procedure by the same physician during the postoperative period. Modifier 78 applies if the patient returns to the OR for an unplanned complication-related procedure. Do not use 79 for related returns — 79 is for procedures unrelated to the original surgery.

06Can 21387 be billed with an E/M on the same day as surgery?

Only if the E/M represents a significant, separately identifiable service beyond the pre-op assessment for the procedure. Append modifier 25 to the E/M code. The decision for surgery on the day of surgery uses modifier 57 on the E/M if the surgery has a 90-day global.

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 combined approach by name from dictation — both incision sites, the fracture pattern encountered, implant type and fixation details, and any concurrent facial fractures treated. That prevents the most common downcode: a payer reducing 21387 to a single-approach orbital repair because the operative note didn't explicitly name both access points.

See how Mira captures CPT 21387 documentation