Open surgical repair of an orbital fracture (excluding blowout type) using bone graft material harvested and placed during the same operative session.

Verified May 8, 2026 · 6 sources ↓

Medicare: $814.31
Work RVU: 12.46
Global, days: 90
Region: Other

Drawn from AAPCMdclarityAaomsCMSMatthew-carlson-di7f

Documentation requirements

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

Source · Editorial brief grounded in 6 cited references ↓

Operative note must confirm fracture type is orbital but explicitly NOT a blowout fracture — payers audit the distinction between 21395/21407 and 21408.
Document the surgical approach by name and incision location; generic 'standard approach' language flags audits.
Describe bone graft source (autograft harvest site, e.g., calvarium, iliac crest) and placement — graft harvest is included in 21408 and cannot be separately billed.
Imaging (CT orbit) in the record confirming fracture location, extent, and absence of blowout pattern to support code selection over 21390/21395.
If modifier 22 is appended, include a narrative detailing increased work — unusual anatomy, complicating comorbidities, extended operative time — beyond the typical procedure.

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 76 Repeat, same physician 77 Repeat, another physician 78 Unplanned return — related 79 Unrelated during global 24 Unrelated E/M during global 25 Significant separate E/M 80 Assistant surgeon LT Left side RT Right side

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

CPT 21408 covers open treatment of an orbital fracture — specifically one that is not a blowout fracture — when the repair requires bone grafting. The graft harvest is included; don't separately bill a bone graft harvesting code. The surgeon accesses the fracture through an incision, reduces the fractured orbital bone, and uses the graft to restore structural integrity of the orbit. This is the highest-complexity code in the 21400–21408 orbital fracture series: 21400 is closed without manipulation, 21406 is open without implant, 21407 is open with implant, and 21408 is open with bone graft.

The 90-day global period applies. All routine post-op visits, wound checks, and stitch removals through day 90 are bundled. Anything unrelated to the orbital fracture repair billed in that window needs modifier 24 or 25. If a second procedure is performed during the same session — for example, repair of a concurrent zygomatic or nasoethmoid fracture — list 21408 first (it carries the higher RVU), append modifier 51 to the secondary code, and verify NCCI edits before submission. Modifier 59 or an X-modifier may be needed to bypass bundling if the secondary procedure is at a distinct anatomic site with separate incision.

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 (12.46) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (24.38) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU	12.46
Practice expense RVU	9.6
Malpractice RVU	2.32
Total RVU	24.38
Medicare national rate	$814.31
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	$814.31
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 21408 get rejected.

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

Wrong code selected: payer downcodes to 21406 or 21407 when operative note doesn't clearly document bone graft harvest and placement.
Blowout fracture diagnosis coded on the claim (e.g., ICD-10 S02.3-series blowout) — payers expect 21390 or 21395 for blowout repairs, not 21408.
Separate bone graft harvesting code billed in addition to 21408 — graft obtaining is bundled and will be denied.
Secondary fracture repair code denied without modifier 51 or 59 when billed same session without NCCI edit bypass documentation.
Global period conflict: post-op E/M billed without modifier 24 or 25 within the 90-day window gets denied as bundled.

Frequently asked questions

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

01What's the difference between 21407 and 21408?

21407 uses an alloplastic or synthetic implant to repair the orbital fracture. 21408 uses autologous or bone graft material harvested during the same session. The graft harvest is included in 21408 — don't bill a separate harvesting code.

02Can I bill 21408 for a blowout fracture repaired with bone graft?

No. Blowout fractures have their own code family: 21395 is the correct code for an orbital floor blowout repaired with bone graft. 21408 is restricted to orbital fractures that are explicitly NOT blowout-type.

03If I repair a concurrent zygomatic fracture at the same session, how do I bill?

List 21408 first (higher RVU), then the zygomatic repair code (e.g., 21366) with modifier 51. Check NCCI edits — if the codes are bundled, you'll need modifier 59 or an X-modifier with documentation of a distinct incision or anatomic site.

04Does the 90-day global include both sides if the orbit fracture was bilateral?

Yes. If you bill bilaterally (modifier 50 or LT/RT with two line items), the 90-day global covers post-op care for both sides. Confirm with the payer whether 21408 is eligible for bilateral billing before submitting with modifier 50 — some carriers require LT/RT instead.

05When is modifier 22 appropriate for 21408?

When the operative work significantly exceeded typical — for example, severely comminuted fracture, prior surgical scarring, or repair of multiple orbital walls requiring additional graft. Attach a written narrative to the claim; without it, most payers reject modifier 22 requests.

06Is 21408 typically performed in an ASC or hospital outpatient setting?

Hospital outpatient (HOPD) is far more common given the complexity and bone graft harvest involved. ASC billing is possible but verify facility credentialing and payer authorization, as the payment differential is substantial — see the site-of-service comparison on this page.

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, non-blowout), surgical approach and incision site, bone graft source and harvest description, and placement technique directly from dictation. This prevents the most common 21408 audit flag: an operative note that documents a graft was used but fails to describe harvest, causing coders to drop to 21407 or payers to deny the graft component outright.

See how Mira captures CPT 21408 documentation