CPT 21267Surgery

Revise eye sockets

CPT 21267 covers surgical procedures to revise or reconstruct the bony eye sockets (orbits), typically performed to correct deformities, injuries, or congenital abnormalities affecting the structure surrounding the eye.

Showing rates for

National Average

Base Medicare rate

$1,560.72

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

20.69

PE RVU (NF)

23.78

MP RVU

3.78

Total RVU

48.25

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Document laterality explicitly in operative report and use RT/LT modifiers even for unilateral procedures
Impact: Prevents automatic denials and requests for medical records; reduces payment delays by 15-20 days on average
When billing with modifier 50 for bilateral procedures, verify payer-specific billing rules (single line with modifier 50 vs. two line items with RT/LT)
Impact: Incorrect bilateral billing format causes denials; proper format secures full $2341.08 bilateral payment versus $1560.72 unilateral
For revision surgeries within global period, append modifier 78 and document specific complication or medical necessity requiring return to OR
Impact: Without modifier 78, claim will deny as included in global period; proper use recovers approximately 70% of base rate
Coordinate documentation with co-surgeons when using modifier 62; ensure both operative reports clearly indicate co-surgery medical necessity
Impact: Inadequate co-surgery documentation results in downcoding to assistant surgeon rates (16% vs 62.5%), losing approximately $730 per surgeon
Separate bone graft harvesting with appropriate add-on codes (20900-20902) when autogenous grafts are obtained from distant sites
Impact: Adds $200-400 in additional reimbursement when documented separately and not bundled into primary procedure
Submit detailed operative report with initial claim for high-dollar procedures rather than waiting for records request
Impact: Reduces processing time by 30-45 days and decreases likelihood of automatic downcoding or denial

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Frequently asked questions

What is the 2025 Medicare reimbursement rate for CPT 21267?

The 2025 Medicare national average reimbursement for CPT 21267 is $1560.72 for both facility and non-facility settings, based on 48.25 total RVUs and the 2025 conversion factor of 32.3465.

Can CPT 21267 be billed bilaterally with modifier 50?

Yes, CPT 21267 can be billed with modifier 50 when bilateral orbital revision is performed during the same operative session. Medicare typically reimburses bilateral procedures at 150% of the unilateral rate, or approximately $2341.08, though payer policies vary.

What documentation is required to prevent medical necessity denials for CPT 21267?

Documentation must include pre-operative imaging showing orbital deformity, evidence of functional impairment (diplopia, vision deficits, enophthalmos measurements), ophthalmology consultation supporting functional necessity, and detailed operative report describing specific anatomical corrections performed.

How many RVUs does CPT 21267 carry in 2025?

CPT 21267 has 48.25 total RVUs in 2025, consisting of 20.69 work RVUs, 23.78 practice expense RVUs, and 3.78 malpractice RVUs, making it a high-complexity surgical procedure.

What is the difference between CPT 21267 and simple orbital fracture repair codes?

CPT 21267 represents complex orbital revision involving reconstruction of the orbital structure, typically with osteotomies and bone grafting, while simpler codes (21385-21408) cover acute fracture repairs. CPT 21267 is used for secondary procedures, congenital corrections, or extensive reconstructions requiring significant orbital remodeling.

Which medical specialties typically bill CPT 21267?

CPT 21267 is primarily billed by oral and maxillofacial surgeons, plastic and reconstructive surgeons, oculoplastic surgeons, craniofacial surgeons, and otolaryngologists with specialized training in complex orbital surgery and hospital privileges for facial bone procedures.

What are common reasons for CPT 21267 claim denials?

Common denials include lack of documented medical necessity, procedure deemed cosmetic without functional component, insufficient documentation for bilateral claims, bundling with other facial procedures, and missing pre-operative diagnostic imaging or functional assessment results.