Open surgical treatment of a mandibular fracture without interdental fixation — the fracture site is exposed and reduced through an open approach, but arch bars, wires, or other interdental fixation devices are not used to stabilize the repair.
Verified May 8, 2026 · 6 sources ↓
- Medicare
- $1,791.29
- Total RVUs
- 53.63
- Global, days
- 90
- Region
- Other
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 name the specific fracture site(s) on the mandible — angle, body, symphysis, parasymphysis, condyle, etc.
- Explicitly confirm that NO interdental fixation (arch bars, wire ligatures, splints) was applied — this is the defining distinction from 21462.
- Document the open surgical approach used to expose and reduce the fracture, including incision location and method of reduction.
- If multiple fracture sites were repaired, document each site separately with its own anatomic location and repair description to support multiple-line billing.
- Record implants or fixation hardware used (plates, screws) or confirm none were used, as this affects code selection versus 21454 or 21470.
- Pre-op imaging (CT or plain film) confirming fracture location and displacement should be referenced in the operative note.
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 6 cited references ↓
CPT 21461 covers open treatment of a mandibular fracture where the surgeon accesses the fracture site directly but does not apply interdental fixation (no arch bars, no wire ligatures between teeth). This distinguishes it from 21462, which requires interdental fixation, and 21470, which covers complicated fractures requiring multiple surgical approaches. The code sits in the 90-day global period, meaning all routine post-op care through day 90 is bundled — separate E/M services during that window need modifier 24 or 25 to survive adjudication.
Multiple mandibular fracture sites in one operative session create a billing complexity: 21461 carries an MUE of one. If you're billing separate fracture sites, each goes on its own line with modifier 59 (or the more specific XS) appended to the additional lines — do not stack units on a single line. If the additional sites involve any shared fixation hardware, modifier 52 on those lines signals reduced services to the payer.
This code is predominantly billed by oral surgeons. Place of service matters: the HOPD and ASC payment rates differ materially (see the Site of Service comparison table). Inpatient hospital (POS 21) and on-campus outpatient hospital (POS 22) are the most common settings reported to CMS.
RVU & reimbursement
Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.
Source · CMS Physician Fee Schedule, RVU26A · January 2026
| Work RVU | 9.08 |
| Practice expense RVU | 43.24 |
| Malpractice RVU | 1.31 |
| Total RVU | 53.63 |
| Medicare national rate | $1,791.29 |
| 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 | $1,791.29 |
HOPD (APC 5165) Hospital outpatient department | $6,048.05 |
ASC (PI J8) Ambulatory surgical center (freestanding) | $3,833.49 |
Common denial reasons
The recurring reasons claims for CPT 21461 get rejected.
Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓
- Billing more than one unit of 21461 on a single claim line — the MUE is one; additional fracture sites must each be on separate lines with modifier 59 or XS.
- Missing documentation that interdental fixation was absent — payers may default to 21462 and deny 21461 as miscoded if the note is ambiguous.
- Bundled code billed alongside 21461 without a modifier, triggering CARC 97 NCCI edit denials.
- Post-op E/M visits billed during the 90-day global period without modifier 24, resulting in automatic bundling denials.
- Incorrect place-of-service code submitted, causing a payment rate mismatch or medical necessity flag for the reported setting.
Frequently asked questions
Source · Generated from the editorial pipeline, verified against 6 cited references ↓
01What is the difference between CPT 21461 and 21462?
02Can I bill 21461 more than once for multiple mandibular fracture sites?
03What modifiers are used if a second fracture repair is performed during the same session?
04Does CPT 21461 have a global period, and what does that mean for post-op billing?
05Is 21461 billed differently in an ASC versus a hospital outpatient department?
06When would CPT 21470 be used instead of 21461?
Sources & references
Editorial content was developed using the following public sources. Last verified May 8, 2026.
- 01CMS Physician Fee Schedule 2026
- 02cms.govhttps://www.cms.gov/files/document/r13033cp.pdf
- 03aapc.comhttps://www.aapc.com/codes/cpt-codes/21461
- 04aapc.comhttps://www.aapc.com/discuss/threads/mandible-fracture-guidance.80095/
- 05findacode.comhttps://www.findacode.com/cpt/21461-cpt-code.html
- 06gomedicalbilling.comhttps://gomedicalbilling.com/codes/cpt/21461
Mira AI Scribe
Mira's AI scribe captures the fracture site by anatomic name, the open approach taken, and — critically — an explicit statement that no interdental fixation was applied. That last detail is the single most audit-sensitive element distinguishing 21461 from 21462; without it in the note, coders are guessing and payers are denying.
See how Mira captures CPT 21461 documentation