Fracture care · Other

21440

Closed treatment of a mandibular or maxillary alveolar ridge fracture, performed by manipulation without surgical incision.

Verified May 8, 2026 · 4 sources ↓

Medicare
$794.27
Work RVU
3.35
Global, days
90
Region
Other
Drawn from CMSAAPCAAOS

Documentation requirements

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

Source · Editorial brief grounded in 4 cited references ↓

  • Mechanism of injury and clinical findings supporting fracture diagnosis (e.g., dental malocclusion, mobility of alveolar segment)
  • Confirmation that treatment was closed — no incision made; manipulation technique described explicitly
  • Specific anatomic site documented: mandibular alveolar ridge vs. maxillary alveolar ridge, with laterality
  • Imaging (periapical, panoramic, or CT) referenced in the note to support fracture characterization
  • Occlusal status assessed pre- and post-manipulation, including any splint or interdental wiring applied
  • Post-reduction plan documented, including immobilization method and follow-up interval within the 90-day global

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

What this code covers

Source · Editorial summary grounded in 4 cited references ↓

CPT 21440 covers closed (non-surgical) treatment of fractures involving the alveolar ridge — the dense bone of the upper or lower jaw that anchors the tooth sockets. Treatment is accomplished through manual manipulation rather than an open incision. This distinguishes it from open treatment codes in the 21440s family, which require surgical exposure.

The 90-day global period means all routine fracture follow-up, including occlusal checks, splint adjustments, and related E/M visits, is bundled into the single procedure payment. Any visit unrelated to the fracture managed during that window requires modifier 24. A same-day E/M that drives the decision to treat requires modifier 57.

This code sits within the head fracture and dislocation subsection of the musculoskeletal CPT range. It is most commonly billed by oral and maxillofacial surgeons and ENT/head and neck specialists, though trauma-trained orthopedic surgeons may encounter it in polytrauma contexts. Correct ICD-10 diagnosis coding to the specific jaw segment and laterality is essential; nonspecific fracture codes are a common audit trigger.

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 (3.35) is the surgeon's own effort — the figure physician pay and productivity targets are built on. The total RVU (23.78) adds practice overhead and malpractice, and is what drives the Medicare payment below.

Work RVU 3.35
Practice expense RVU 19.95
Malpractice RVU 0.48
Total RVU 23.78
Medicare national rate $794.27
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

SettingMedicare rate (national)
Office (PFS non-facility)
Procedure performed in physician's office
$794.27
HOPD (APC 5164)
Hospital outpatient department
$3,387.27
ASC (PI P3)
Ambulatory surgical center (freestanding)
$670.01

Common denial reasons

The recurring reasons claims for CPT 21440 get rejected.

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

  • ICD-10 fracture code too nonspecific — missing laterality or jaw segment specificity triggers medical necessity edits
  • Same-day E/M billed without modifier 57, resulting in bundling denial under the global package rules
  • Operative note describes incision or open exposure, contradicting the closed-treatment code and triggering downcoding or denial
  • Claim submitted without adequate imaging documentation on file, causing medical necessity denial on pre-payment review
  • Modifier 24 omitted on follow-up E/M visits within the 90-day global, causing those visits to be denied as included services

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 4 cited references ↓

01What distinguishes 21440 from open alveolar ridge fracture codes?
21440 is closed treatment — manipulation only, no surgical incision. Open treatment codes require operative exposure of the fracture site. If your operative note describes any incision into the fracture zone, 21440 is the wrong code and the claim is vulnerable to downcoding or fraud scrutiny.
02How long is the global period for 21440, and what does it include?
21440 carries a 90-day global. That covers the day-of procedure, the day-before visit, and all routine fracture management through day 90 — including splint checks, wire adjustments, and related E/M visits. Unrelated conditions billed in that window need modifier 24.
03Can 21440 be billed for both mandibular and maxillary alveolar ridge fractures treated at the same encounter?
If both the mandibular and maxillary alveolar ridges are fractured and treated at the same encounter, modifier 51 on the secondary procedure is appropriate. Document each site separately in the operative note. Some payers may also require modifier 59 or XS to distinguish anatomic sites.
04What modifier applies if the same-day E/M drove the decision to perform closed treatment?
Modifier 57 applies when an E/M service on the day of or the day before a procedure with a 90-day global results in the decision to perform that procedure. Without modifier 57, the E/M will be bundled into the surgical payment and denied.
05Is 21440 appropriate when the patient requires sedation or anesthesia for manipulation?
Yes — the code describes closed treatment regardless of anesthesia type. The need for sedation or general anesthesia does not convert this to an open procedure code. Document the anesthesia type in the procedure note; anesthesia is billed separately by the anesthesia provider.
06What ICD-10 codes pair with 21440?
Use fracture codes from the S02.6 range (alveolar fractures of mandible) or S02.4 range (maxillary fractures) with appropriate laterality and encounter type (initial = A, subsequent = D, sequela = S). Nonspecific or unspecified fracture codes increase audit and denial risk.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

  1. 01CMS Physician Fee Schedule 2026
  2. 02
    aapc.com
    https://www.aapc.com/codes/cpt-codes/21440
  3. 03
    cms.gov
    https://www.cms.gov/files/document/2025nccimedicarepolicymanualcompletepdf.pdf
  4. 04
    aaos.org
    https://www.aaos.org/quality/coding-and-reimbursement/

Mira Scribe

Mira's AI scribe captures the mechanism of injury, the specific alveolar ridge segment (mandibular vs. maxillary, with laterality), confirmation that no incision was made, manipulation technique, pre- and post-reduction occlusal status, and any splint or wiring applied. That documentation directly prevents downcoding to an unspecified fracture code and shields against closed-vs-open treatment disputes on audit.

See how Mira captures CPT 21440 documentation

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