CPT 21400Surgery

Closed tx orbit w/o manipulj

CPT code 21400 covers the non-surgical treatment of a broken bone in the eye socket (orbital fracture) that does not require the doctor to physically realign the bones. The fracture is monitored and managed conservatively without manipulation.

Showing rates for

National Average

Base Medicare rate

$216.40

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

1.5

PE RVU (NF)

4.91

MP RVU

0.28

Total RVU

6.69

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

NCCI bundling edits

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Billing tips

Clearly document 'without manipulation' in the procedure note to distinguish from CPT 21401 (with manipulation) which reimburses higher but requires documentation of manual reduction
Impact: Prevents upcoding allegations and potential $80-$150 repayment demands; ensures accurate code selection between 21400 ($216.40) and 21401 codes
Bill in non-facility setting when providing office-based evaluation and treatment planning; facility rate is $46.26 lower
Impact: Maximizes reimbursement by $46.26 per encounter when performed in physician office rather than hospital outpatient department
Always append LT or RT modifier as orbital procedures require laterality designation; bilateral fractures require two line items with RT and LT or modifier 50
Impact: Prevents automatic denials; bilateral coding with modifier 50 typically reimburses at 150% of single-side rate ($324.60 vs $216.40)
Separately bill initial comprehensive imaging interpretation (CPT 70480-70482 for orbital CT) when performed and documented by your practice
Impact: Additional $100-$250 reimbursement when radiological interpretation is separately documented and not performed by hospital radiology
Document global period follow-up visits thoroughly; 21400 carries a 90-day global period where routine post-treatment care is bundled
Impact: Prevents denials for follow-up visits billed separately; only new problems or complications can be billed during 90-day global with modifier 24, potentially recovering $150-$300 for legitimate separate services
For Medicare patients, verify the fracture occurred within a timeframe consistent with acute treatment; delayed presentations may require different coding or medical necessity documentation

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Frequently asked questions

What is the Medicare reimbursement rate for CPT code 21400 in 2025?

The 2025 Medicare national average reimbursement for CPT 21400 is $216.40 in non-facility settings and $170.14 in facility settings. Actual payment may vary based on geographic location and MAC-specific adjustments.

What is the difference between CPT 21400 and 21401?

CPT 21400 is for closed treatment of orbital fracture WITHOUT manipulation, while 21401 involves WITH manipulation. The key difference is whether the physician manually realigns or reduces the fracture fragments. Documentation must explicitly state whether manipulation was performed, as this determines correct code selection and affects reimbursement.

Can I bill an E/M code with CPT 21400 on the same day?

Yes, you can bill an E/M code with modifier 25 when a separately identifiable evaluation and management service is performed on the same day. This typically applies when the initial trauma evaluation, history, examination, and medical decision-making to pursue closed treatment is documented separately from the procedure note. The E/M must be above and beyond the usual pre-procedure assessment.

What is the global period for CPT code 21400?

CPT 21400 has a 90-day global period. All routine follow-up care related to the orbital fracture treatment is included in the initial reimbursement and cannot be billed separately. Only treatment for complications or unrelated conditions can be billed during this period with appropriate modifiers.

Do I need to use a modifier for laterality with CPT 21400?

Yes, laterality modifiers LT (left) or RT (right) are required for CPT 21400. Orbital procedures must specify which side was treated. For bilateral orbital fractures treated on the same date, bill with modifier 50 or as two separate line items with LT and RT modifiers depending on payer preference.

How many RVUs is CPT code 21400 worth in 2025?

CPT 21400 has a total of 6.69 RVUs in 2025, consisting of 1.5 work RVUs, 4.91 non-facility practice expense RVUs (3.48 facility PE RVUs), and 0.28 malpractice RVUs. These values are from the CMS Medicare Physician Fee Schedule RVU25A released December 23, 2024.

What documentation is required to bill CPT 21400 without risk of denial?

Required documentation includes mechanism and date of injury, clinical examination findings (vision, eye movements, globe position), imaging review confirming orbital fracture, explicit statement that no manipulation was performed, treatment plan with monitoring schedule, patient education, and laterality designation. Clear documentation distinguishing why treatment (vs observation) and why no manipulation was necessary helps establish medical necessity.