CPT 21407Surgery

Opn tx orbit fx w/implant

CPT 21407 covers surgical repair of a broken eye socket (orbital fracture) through an open incision with placement of an implant to reconstruct the bone. This is a complex facial trauma procedure requiring precise surgical technique to restore the eye's protective bony structure.

Showing rates for

National Average

Base Medicare rate

$636.26

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

9.02

PE RVU (NF)

9.42

MP RVU

1.23

Total RVU

19.67

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

NCCI bundling edits

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Billing tips

Document the specific implant material, dimensions, and manufacturer in operative report
Impact: Prevents denials for lack of medical necessity; implant type justifies code selection over 21406 (without implant) which has lower RVU value of 16.34
Clearly differentiate timing of repair (acute vs delayed) and anatomical location (floor, medial wall, lateral wall) in documentation
Impact: Supports medical necessity and prevents downcoding; timing affects global period considerations and modifier application
Bill facility and non-facility rates identically at $636.26 since PE RVUs are equal (9.42) for this procedure
Impact: No setting-based reimbursement differential; unusual for surgical codes but verified in 2025 fee schedule
Separately bill for implant supply costs using appropriate HCPCS codes (L8600-L8699 range) when facility billing
Impact: Implant materials not included in professional fee; can add $500-$3,000 in facility reimbursement depending on implant type
Do not bundle with nasolacrimal duct probing/stenting if documented as separate medical necessity
Impact: Codes 68810-68816 may be separately billable with modifier 59 if lacrimal system addressed independently; potential additional $150-$400
Consider modifier 22 for revision cases with significant scar tissue or bone graft harvesting from distant site
Impact: Well-documented modifier 22 claims can achieve 25-40% increase ($159-$254 additional) but require peer review and detailed operative time/complexity justification

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 21407 in 2025?

The 2025 Medicare national average payment for CPT 21407 is $636.26 for both facility and non-facility settings. This is based on 19.67 total RVUs (9.02 work RVU, 9.42 PE RVU, 1.23 MP RVU) multiplied by the 2025 conversion factor of 32.3465. Local rates may vary based on geographic practice cost indices.

What is the difference between CPT 21406 and 21407?

CPT 21406 covers open treatment of orbital fracture without implant placement (16.34 RVUs), while CPT 21407 includes placement of an implant for structural support (19.67 RVUs). The implant component in 21407 adds approximately 3.33 RVUs of work and requires specific documentation of the implant material, size, and placement to justify the higher-valued code.

Can CPT 21407 be billed bilaterally with modifier 50?

Yes, CPT 21407 can be billed with modifier 50 for bilateral orbital fracture repair with implants performed during the same operative session. Medicare typically reimburses bilateral procedures at 150% of the unilateral rate (approximately $954.39 total) rather than 200%, subject to the bilateral surgery indicator rules in the fee schedule.

What documentation is required to support CPT 21407 billing?

Essential documentation includes pre-operative CT imaging showing fracture extent, detailed operative report describing surgical approach and exposure, specific implant material/dimensions/manufacturer, anatomical placement location, confirmation of fracture reduction, and medical necessity justification. Missing implant specifications is the most common reason for denials or downcoding to 21406.

What modifiers are commonly used with CPT 21407?

Common modifiers include 50 (bilateral procedure), 51 (multiple procedures), RT/LT (laterality), 22 (increased complexity for severe comminution or revision cases), 78 (return to OR during global period), and 80 (assistant surgeon). Modifier 22 requires extensive documentation but can increase reimbursement by 20-40% for appropriately complex cases.

How many RVUs is CPT 21407 worth in 2025?

CPT 21407 carries 19.67 total RVUs in 2025, comprised of 9.02 work RVUs, 9.42 practice expense RVUs (same for both facility and non-facility), and 1.23 malpractice RVUs. This makes it a high-value surgical code reflecting the technical complexity of orbital fracture repair with implant reconstruction.

Can I bill separately for the orbital implant material with CPT 21407?

For professional fee billing, the implant is included in CPT 21407 reimbursement. However, facilities (hospitals/ASCs) can separately bill for implant supply costs using appropriate HCPCS codes (L8600-L8699 range for implantable devices). Surgeons should not separately bill for the implant material as it is considered included in the surgical service.