Open repair of an orbital floor blowout fracture using autogenous bone graft to restore bony structure and volume.

Verified May 8, 2026 · 6 sources ↓

Medicare: $896.81
Work RVU: 14.33
Global, days: 90
Region: Other

Drawn from CMSAAPCCgsmedicareMdclarity

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Mechanism of injury and clinical findings confirming orbital floor fracture (e.g., enophthalmos, diplopia, hypesthesia of infraorbital nerve)
Imaging (CT orbit) demonstrating fracture pattern and extent of bony defect
Operative note specifying the surgical approach by name and incision location
Documentation of autogenous bone graft harvest site, graft dimensions or volume, and method of placement
Confirmation that the graft is autogenous — payer auditors will flag notes that don't distinguish autograft from allograft or alloplastic implant
Pre- and post-operative ophthalmologic or functional assessment when diplopia or ocular motility restriction is the presenting complaint

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 51 Multiple procedures 58 Staged or related 59 Distinct service 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 21395 covers open surgical treatment of an orbital floor fracture where the surgeon accesses the fracture site through a skin incision, reduces the displaced bony fragments, and fills the defect with a bone graft harvested from the patient's own body. This distinguishes it from orbital floor repairs using synthetic implants or alloplastic materials — the autograft harvest is what drives the code selection here.

The 90-day global period applies. That window includes the day-before-surgery visit, the procedure itself, and all routine post-op care through day 90. If you're treating an unrelated condition during the global period, append modifier 79. If a planned staged revision is needed during the global window, use modifier 58 — not 79.

Site of service matters for this code: HOPD and ASC payments differ significantly (see the Site of Service comparison table). Payers vary on what constitutes adequate graft documentation; operative notes must specify the graft harvest site, graft dimensions or volume, and placement technique to survive audit.

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 (14.33) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (26.85) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	14.33
Practice expense RVU	9.87
Malpractice RVU	2.65
Total RVU	26.85
Medicare national rate	$896.81
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	$896.81
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 21395 get rejected.

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

Operative note fails to specify that the graft material is autogenous, triggering a code mismatch with implant-based orbital repair codes
Missing or inadequate imaging documentation; payers require CT orbit to confirm fracture prior to authorizing open repair
Unbundling denial when graft harvest site is billed separately without supporting NCCI modifier where bundling rules apply
Lack of prior authorization — many commercial payers require PA for open orbital fracture repair with grafting
ICD-10 diagnosis code mismatch; fracture laterality and encounter type (initial vs. subsequent) must align with the operative claim

Frequently asked questions

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

01What separates CPT 21395 from other orbital fracture repair codes?

21395 specifically requires open treatment of the orbital floor with autogenous bone graft. Repairs using alloplastic implants or without grafting map to different codes. Graft source documentation is the deciding factor auditors check first.

02Can I separately bill for the bone graft harvest site?

Generally no. The graft harvest is considered integral to the procedure under NCCI bundling principles for musculoskeletal surgery. Check the NCCI PTP table for the specific code pair before unbundling — modifier 59 or an X-modifier is only appropriate when the edit allows it (modifier indicator 1) and the documentation supports a distinct service.

03What global period applies to 21395?

90-day global. All routine post-op visits, wound care, and stitch removal through day 90 are included. Bill unrelated procedures during that window with modifier 79; staged related procedures use modifier 58.

04What ICD-10 codes pair with 21395?

Orbital floor fracture codes from the S02.3- category are the primary pairings. Specify laterality and use the correct encounter type — initial encounter (A), subsequent encounter (D), or sequela (S). Payers deny when the encounter type doesn't match the clinical context of the claim.

05Is modifier 22 ever appropriate for 21395?

Yes, when the operative complexity is substantially greater than typical — for example, severely comminuted fracture requiring extensive graft shaping, significant scarring from prior trauma, or prolonged operative time. The operative note must document the specific factors that increased work; a generic 'difficult case' notation won't support the modifier through audit.

06How does site of service affect reimbursement for 21395?

HOPD and ASC payments differ materially for this code — see the Site of Service comparison table on this page. Confirm your facility's contracted rates and ensure the place-of-service code on the claim matches where the procedure was actually performed; mismatches are a common clean-claim failure point.

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 fracture mechanism, CT findings, surgical approach name, graft harvest site and dimensions, and graft placement technique directly from dictation. This prevents the most common audit flag for 21395 — operative notes that don't explicitly confirm autogenous graft material and harvest location, which leads to payer downcoding or denial.

See how Mira captures CPT 21395 documentation