Open surgical repair of an orbital fracture (not a blowout type) without placement of any implant or synthetic material.

Verified May 8, 2026 · 7 sources ↓

Medicare: $542.43
Total RVUs: 16.24
Global, days: 90
Region: Other

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Documentation requirements

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

Source · Editorial brief grounded in 7 cited references ↓

Operative note must specify the fracture as non-blowout type and identify the orbital wall(s) involved
Document that no implant or alloplastic material was placed — distinguishes 21406 from 21407
Record the surgical approach (e.g., subciliary, transconjunctival, coronal, or upper eyelid incision) by name
Preoperative CT imaging report confirming fracture location, displacement, and absence of blowout pattern
Document displacement status of fracture to support ICD-10-CM code specificity
If modifier 22 is appended, include a separate narrative quantifying additional work (time, complexity, comminution)

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 50 Bilateral procedure 51 Multiple procedures 52 Reduced services 59 Distinct service 62 Co-surgeons 76 Repeat, same physician 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon 24 Unrelated E/M during global RT Right side LT Left side AS PA/NP/CNS assistant

What this code covers

Source · Editorial summary grounded in 7 cited references ↓

CPT 21406 covers open reduction of an orbital fracture that is not a blowout fracture, performed without implant placement. The surgeon incises down to the fractured orbital bone, manually realigns the displaced fragments, and stabilizes them without inserting alloplastic or synthetic implants. The distinction from blowout fractures is critical — blowout repairs targeting the orbital floor or medial wall use a separate code family (21385–21395). If an implant is placed during this same procedure, step up to 21407; if bone grafting is required, use 21408 instead.

Fracture terminology matters here. An 'open' treatment refers to surgical access to the fracture site, not to whether the fracture itself has broken through skin. A closed fracture can still require open treatment. Document this distinction explicitly — operative notes that conflate fracture type with treatment approach are a consistent audit flag. ICD-10-CM coding should specify displacement status; fractures not documented as displaced default to nondisplaced under ICD-10-CM conventions.

This code carries a 90-day global period. All routine follow-up, wound checks, and suture removal through postoperative day 90 are bundled. Bill unrelated E/M visits in that window with modifier 24. If a co-surgeon assists (common in complex periorbital trauma), both surgeons bill 21406 with modifier 62. When multiple facial fractures are repaired in the same session, report each separately to the extent NCCI edits allow; modifier 59 or an X-modifier may be needed to bypass component edits, and clinical documentation must support each as a distinct, medically necessary repair.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	7.23
Practice expense RVU	7.68
Malpractice RVU	1.33
Total RVU	16.24
Medicare national rate	$542.43
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	$542.43
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 21406 get rejected.

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

Upcoded to 21407 or 21408 without documentation of implant or bone graft placement
ICD-10-CM fracture code specifies blowout pattern, creating a mismatch with 21406 which excludes blowout fractures
Routine post-op E/M visits billed without modifier 24 during the 90-day global period
Multiple facial fracture repairs billed together without modifier 59 or X-modifier to bypass NCCI bundling edits
Co-surgeon claim missing modifier 62, or only one of two co-surgeons appended it

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 7 cited references ↓

01What separates 21406 from 21407 and 21408?

All three cover open treatment of non-blowout orbital fractures. Use 21406 when no implant is placed. Use 21407 when an alloplastic or synthetic implant is inserted. Use 21408 when bone grafting is performed — that code includes harvesting the graft.

02Can 21406 be billed bilaterally with modifier 50?

Bilateral orbital fracture repair in a single session can be reported with modifier 50, but verify with the specific payer first. Some carriers do not recognize modifier 50 for this code family, and Medicare bilateral payment caps at 150% of the single-procedure allowable. The Medicare Physician Fee Schedule Look-Up Tool confirms bilateral indicator status.

03How do you handle a co-surgeon scenario — for example, oculoplastics and oral surgery both operating?

Both surgeons bill 21406 with modifier 62. Each operative note must independently document the distinct portion of the procedure each surgeon performed. If one surgeon assists without co-surgeon responsibilities, that surgeon uses modifier 80 or AS instead.

04Does 21406 cover the blowout fracture repair codes (21385–21395)?

No. The blowout series targets orbital floor and medial wall fractures caused by pressure transmission — a distinct mechanism and anatomy. CPT 21406 explicitly excludes blowout fractures. Billing 21406 when imaging and the operative note describe a blowout pattern will generate a diagnosis-procedure mismatch denial.

05A patient returns 3 weeks post-op with a displaced fragment requiring revision. What code applies?

If the revision is directly related to the original repair, bill 21406 again with modifier 78 (unplanned return to OR for a related procedure during the global period). Modifier 78 signals the work is related and within global — payment will be reduced to intraoperative RVUs only, as pre- and post-op are already bundled in the original global.

06What ICD-10-CM codes pair with 21406?

Codes from the S02.8 range (fracture of other specified skull and facial bones) and S02.3x (orbital floor fractures coded to non-blowout specificity) are typical pairings. Document displacement status — ICD-10-CM defaults to nondisplaced if not specified. Laterality must also be captured.

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 orbital wall(s) involved, the surgical approach by name, explicit confirmation that no implant was placed, fracture displacement status, and whether a co-surgeon participated — all from dictation. This prevents the most common 21406 denials: blowout-versus-non-blowout mismatch on the ICD-10 side, and missing implant documentation that triggers a step-down audit to 21407.

See how Mira captures CPT 21406 documentation