Open surgical repair of an orbital fracture with placement of an implant to stabilize the bony orbit surrounding the eye socket.

Verified May 8, 2026 · 7 sources ↓

Medicare: $577.50
Work RVU: 8.79
Global, days: 90
Region: Other

Drawn from CMSBedrockbillingAAPCFastrvuMdclarity

Documentation requirements

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

Source · Editorial brief grounded in 7 cited references ↓

Specify the mechanism of injury and confirm fracture is orbital but not a blowout fracture — code selection hinges on this distinction
Name the surgical approach used (transcutaneous lower eyelid, transconjunctival, coronal, etc.) — operative notes that say 'standard approach' are audit flags
Document the implant type, material, and size placed to stabilize the orbit
Confirm laterality — left or right orbit — to support LT or RT modifier assignment
If modifier 22 is appended, include a separate attestation detailing why the procedure required substantially more work than typical (e.g., comminuted fracture, prior surgery, scar tissue)

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 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 LT Left side RT Right side XS Separate structure

What this code covers

Source · Editorial summary grounded in 7 cited references ↓

CPT 21407 covers open treatment of an orbital fracture — not a blowout fracture — where the surgeon makes an incision directly over the fracture site and places an implant to restore orbital structure and stability. This distinguishes it from 21406 (open treatment without implant) and from blowout-specific codes. The implant component is essential to code selection; if no implant is used, 21406 applies.

The 90-day global period covers the operative day, the pre-op day-before visit, and all routine post-op management through day 90. Complications requiring a return to the OR for a related issue use modifier 78; unrelated procedures in the global window use modifier 79. Separate E/M visits during the global period require modifier 24 (unrelated) or 25 (same-day, significant and separately identifiable).

With 1,078 NCCI edits associated with this code, bundling is a live audit risk. Procedures performed to gain access to the fracture site — such as an osteotomy — are generally considered integral and not separately billable unless documented as a distinct, independently necessary service. Laterality modifiers (LT/RT) are required when the fracture is unilateral; modifier 50 applies only if both orbits are repaired in the same session.

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 (8.79) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (17.29) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	8.79
Practice expense RVU	7.29
Malpractice RVU	1.21
Total RVU	17.29
Medicare national rate	$577.50
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	$577.50
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 21407 get rejected.

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

Missing or ambiguous laterality — payers require LT or RT; claims without them often reject outright
Upcoding challenge when implant use is not clearly documented — payers may down-code to 21406 if the implant isn't named in the operative note
Bundling of access procedures (e.g., osteotomy) billed separately without documentation of independent medical necessity
Modifier 22 appended without an accompanying narrative justification — payers deny the additional payment without it
Global period violations — E/M or minor procedure claims during the 90-day window without modifier 24 or 79

Frequently asked questions

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

01What separates 21407 from 21406?

Implant placement. If the surgeon repairs the orbital fracture through an open approach but does not place an implant, bill 21406. Implant use — regardless of size or material — moves you to 21407. The operative note must name the implant.

02Can 21407 be billed for a blowout fracture?

No. Blowout fractures of the orbital floor or medial wall have their own code family. CPT 21407 covers orbital fractures that are not blowout fractures. Misapplying 21407 to a blowout repair is an audit target.

03Is an osteotomy performed for access separately billable with 21407?

Generally no. AAPC forum guidance and payer audit patterns treat access osteotomies as integral to the primary fracture repair. To bill separately, document that the osteotomy was a distinct, independently necessary procedure — not just a means of exposure.

04When does modifier 50 apply versus billing LT and RT separately?

Modifier 50 applies when both orbits are repaired with implants in the same operative session. If only one orbit is repaired, use LT or RT alone. Bilateral orbital fracture repair in the same session is uncommon; payers may request records when modifier 50 appears on this code.

05What triggers modifier 22 on 21407, and what documentation is required?

Modifier 22 is warranted when the procedure required substantially more physician work than typical — for example, a severely comminuted fracture, prior orbital surgery with dense scarring, or unusual anatomical complexity. Append a written attestation to the claim describing the specific factors that increased work. Without it, payers routinely deny the additional reimbursement.

06How does the 90-day global period affect post-op billing?

All routine follow-up through day 90 is included in the global. Bill modifier 24 for unrelated E/M visits in that window, modifier 78 for a related unplanned return to the OR, and modifier 79 for an unrelated procedure. Billing post-op visits without these modifiers triggers automatic bundling and denial.

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 classification (orbital vs. blowout), the named surgical approach, implant type and material, and confirmed laterality directly from dictation. That specificity prevents down-coding to 21406, blocks laterality-related rejections, and gives modifier 22 the supporting narrative it needs before the claim leaves the practice.

See how Mira captures CPT 21407 documentation