Closed treatment of an orbital fracture (excluding blowout fractures) requiring no bone manipulation or repositioning

Verified May 8, 2026 · 6 sources ↓

Medicare: $238.48
Total RVUs: 7.14
Global, days: 90
Region: Other

Drawn from CMSAAPCMdclarityCdn-links

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

CT imaging findings confirming orbital fracture type and location, with explicit notation that the fracture is not a blowout
Clinical rationale for non-operative management — document why manipulation was not required
Fracture location specified (e.g., orbital rim, superior wall, medial wall) with blowout involvement ruled out
Physical exam findings including extraocular motility, enophthalmos assessment, and infraorbital nerve function
Imaging personally reviewed by the treating provider, with review documented in the note
Assessment and plan clearly stating closed treatment without manipulation as the chosen management approach

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 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 58 Staged or related 78 Unplanned return — related 79 Unrelated during global LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 21400 covers non-operative management of an orbital wall fracture — blowout fractures are explicitly excluded. The provider evaluates the fracture clinically and radiographically, determines that the bony anatomy does not require physical repositioning, and manages the injury conservatively. CT imaging is standard to confirm fracture type, rule out blowout involvement, and document that manipulation is not warranted.

The 90-day global period applies. Any E/M visit on the same day as the fracture treatment decision requires modifier 25 to be separately billable. If the same physician later bills an unrelated E/M during the 90-day global window, modifier 24 is required. Surgeons who subsequently decide operative intervention is needed bill the open or reduction procedure with modifier 58 (staged/planned) or 78 (unplanned return to OR for a related complication).

The blowout exclusion is the most common coding error with this code. A medial wall or floor fracture that meets blowout criteria belongs under a different code family. Document the fracture location, the CT findings, and the explicit clinical rationale for non-operative management — payers audit orbital fracture claims closely given the overlap between 21400 and blowout codes.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	1.46
Practice expense RVU	5.43
Malpractice RVU	0.25
Total RVU	7.14
Medicare national rate	$238.48
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	$238.48
HOPD (APC 5162) Hospital outpatient department	$551.01
ASC (PI A2) Ambulatory surgical center (freestanding)	$295.47

Common denial reasons

The recurring reasons claims for CPT 21400 get rejected.

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

Blowout fracture diagnosis code submitted with 21400 — blowout fractures require a different code and will trigger automatic denial
E/M billed same-day without modifier 25, causing the evaluation to bundle into the fracture treatment
Insufficient documentation of medical necessity for non-operative management — no stated rationale for why manipulation was not performed
Missing or unlinked CT imaging documentation; payers require confirmed imaging review to establish fracture diagnosis
Bilateral modifier or laterality modifier missing when orbital fracture is clearly unilateral and payer requires side specification

Frequently asked questions

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

01What separates 21400 from a blowout fracture code?

21400 explicitly excludes blowout fractures. A blowout involves a fracture of the thin interior orbital walls (floor or medial wall) caused by increased intraorbital pressure, typically producing enophthalmos or extraocular muscle entrapment. If CT confirms blowout anatomy, 21400 is the wrong code regardless of whether manipulation occurred.

02Can I bill an E/M on the same day as 21400?

Yes, but only with modifier 25 on the E/M. The E/M must be a significant, separately identifiable service beyond the fracture evaluation itself — document it as distinct work in the note. Without modifier 25, the E/M bundles and will be denied.

03Does 21400 require the provider to be a surgeon or specialist?

No specialty restriction exists in the CPT descriptor. The code is billed by the treating provider — ophthalmologist, oral/maxillofacial surgeon, plastic surgeon, or ENT — whoever performs the fracture evaluation and manages the injury.

04What ICD-10 codes pair with 21400?

Orbital fracture codes from the S02.8x family are typical pairings — for example, S02.85XA (orbital floor fracture, initial encounter) when blowout is not documented. Confirm the fracture site with CT and select the most specific ICD-10 code available; avoid unspecified fracture codes when imaging identifies the location.

05If the patient returns within the 90-day global and needs surgery, how do I bill the operative procedure?

Use modifier 58 if the operative procedure was staged or planned from the initial encounter. Use modifier 78 if the patient returns to the OR for an unplanned, related complication. Either modifier opens the global and allows the surgical procedure to be billed separately.

06Is prior authorization typically required for 21400?

Most commercial payers do not require PA for closed fracture treatment without manipulation, but trauma payers and workers' compensation programs vary. Confirm with the specific payer before the encounter when the clinical scenario allows — ED presentations won't permit pre-auth, but follow-up fracture management visits sometimes do.

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 location, CT findings reviewed by the provider, the explicit exclusion of blowout fracture involvement, and the documented rationale for non-operative management without bone manipulation. This prevents the two most common denials: blowout misclassification and insufficient medical necessity documentation for conservative treatment.

See how Mira captures CPT 21400 documentation