🧬 CPT 21386: Quick Reference: Open Treatment of Orbital Floor Blowout Fracture (Periorbital Approach)

Last Updated: February 2026
Status: 2025 Medicare Fee Schedule Compliant
Specialty Tags:

QUICK REFERENCE

Element	Details
Code	21386
Code Type	Surgical Procedure - Orbital/Periorbital Surgery
Procedure Type	Open treatment of orbital floor blowout fracture, periorbital approach (without implant)
Global Period	090 days (major surgical procedure)
Work RVU (2025)	4.35 RVU
Practice Expense RVU (2025, Non-Facility)	2.01 RVU
Practice Expense RVU (2025, Facility)	1.02 RVU
Malpractice RVU (2025)	0.31 RVU
Total RVU (2025, Non-Facility)	6.67 RVU
Total RVU (2025, Facility)	5.68 RVU
2025 Medicare Fee (Non-Facility)	~ $215.86 (6.67 R V U \times$ 32.35 CF × GPCI)
2025 Medicare Fee (Facility)	~ $183.71 (5.68 R V U \times$ 32.35 CF × GPCI)
Conversion Factor (2025)	$32.35
Estimated Commercial Insurance	$1,200 - 3,500
Common Place of Service	Hospital outpatient (22), ASC (24), Office OR (11)
Specialty	Oculoplastic Surgery, Ophthalmology, Otolaryngology, Plastics
Procedure Time	45-90 minutes

📋SHORT DEFINITION - CPT 21386

CPT 21386 describes open surgical repair of an orbital floor fracture (blowout fracture) using a periorbital approach (incision near the lower eyelid) without implant placement - also called “simple” repair or primary closure. The surgeon reduces herniated orbital contents and closes the fracture site. This is typically performed for uncomplicated orbital floor fractures without significant volume loss or when primary tissue closure is adequate.

LONG DEFINITION - CPT 21386

Overview

CPT 21386 is a surgical code for open repair of orbital floor fractures WITHOUT implant. This is the simpler, less invasive approach to fracture repair where the surgeon uses a periorbital (near-eyelid) incision to reduce the fracture and close it primarily without needing to place an implant to support the orbital floor.

Clinical Context & Indications

Common Indications for 21386:

Simple, Uncomplicated Orbital Floor Fracture
- Small, clean fracture without significant comminution
- Minimal volume loss
- No significant enophthalmos risk
- Primary closure of fracture possible
Limited Muscle Entrapment
- Minimal muscle involvement
- Quick release without significant hemostasis needed
- Restoration of function without implant support
Patient Factors
- Good orbital anatomy pre-injury
- Adequate blood supply for healing
- Low infection risk
- Able to comply with post-operative care
Timing
- Usually performed within first few weeks
- Before significant scarring/fibrosis develops
- Early intervention may prevent need for implant

Anatomical Context (See 21390 section for details on orbital floor anatomy)

Procedure Technique

Patient Preparation:

General anesthesia (same as 21390)
Supine or semi-recumbent positioning
Prep and drape

Operative Technique - Periorbital (Transconjunctival) Approach:

Incision:
- Same as 21390 (transconjunctival incision in lower conjunctiva)
- Careful dissection to orbital floor fracture site
Exposure & Assessment:
- Fracture visualized
- Herniated contents identified
- Muscle involvement assessed
- Fracture size and gap measured
Reduction:
- Herniated orbital tissue (fat, muscle) reduced back into orbit
- Extraocular muscles carefully released if entrapped
- Careful hemostasis achieved
Closure - KEY DIFFERENCE FROM 21390:
- NO implant placed
- Fracture edges reduced together (primary closure)
- Fracture site closed with sutures (if needed) or left to heal
- Relies on bone healing and scar tissue formation
- May use absorbable or non-absorbable sutures to hold reduction
Post-Operative:
- Conjunctival wound closed (self-sealing)
- No need for implant removal in future
- Simpler post-operative course

When NOT to Use 21386 (When to use 21390 instead):

Large fracture with significant volume loss (need implant support)
Significant enophthalmos at risk
Comminuted (fragmented) fracture (implant needed for support)
Inadequate blood supply for healing without implant

Duration

Typically 45-90 minutes (slightly less than 21390 due to no implant placement/positioning)

KEY DISTINCTIONS - CPT 21386 vs 21390

Feature	21386 (Periorbital, No Implant)	21390 (Periorbital, With Implant)
Approach	Periorbital (lower conjunctiva)	Periorbital (lower conjunctiva)
Fracture Type	Simple, uncomplicated	Complex, large, or comminuted
Volume Loss	Minimal	Significant
Implant	None	Present (silicone, Medpor, titanium, etc.)
Closure	Primary closure, reliant on bone healing	Implant reconstructs floor
enophthalmos Risk	Low	Higher (addressed by implant)
Work RVU	4.35	4.89
Total RVU (Non-Facility)	6.67	7.62
Medicare Fee (Non-Facility)	~$216	~$247
Procedure Time	45-90 min	60-120 min
Recovery	Faster	Standard
Complexity	Moderate	Moderate-High

When to Use 21386 vs 21390:

21386: Small fracture, good bone edges, no need for volume support, patient motivated for good healing
21390: Large defect, significant comminution, volume loss, or implant needed for optimal outcome

WORK RELATIVE VALUE UNITS (wRVUs) & COMPONENTS - CPT 21386

Work RVU Breakdown (2025)

RVU Component	Value	What It Represents
Work RVU	4.35	Physician work, technical skill, surgical time, decision-making
Practice Expense RVU (non-facility)	2.01	Surgical supplies, instruments, staff support (no implant)
Practice Expense RVU (facility)	1.02	Lower in facility (hospital/ASC provides operating room)
Malpractice RVU	0.31	Malpractice insurance and liability (major surgery)
TOTAL RVU (non-facility)	6.67	Total relative value units
TOTAL RVU (facility)	5.68	Total relative value units (lower)

RVU Conversion to Dollar Amount (2025)

Formula: RVU × Conversion Factor (CF) × Geographic Practice Cost Index (GPCI) = Payment

2025 Medicare Conversion Factor: $32.35

Typical Calculations (Non-Facility, GPCI = 1.0):

4.35 wRVU × $32.35 = * *$ 140.72** (work component)
2.01 PE RVU × $32.35 = * *$ 65.07** (practice expense)
0.31 MP RVU × $32.35 = * *$ 10.03** (malpractice)
Total = ~$215.86 per procedure (non-facility, GPCI 1.0)

Facility-Based (Hospital/ASC):

4.35 wRVU × $32.35 = * *$ 140.72** (work component, same)
1.02 PE RVU × $32.35 = * *$ 33.00** (practice expense, lower)
0.31 MP RVU × $32.35 = * *$ 10.03** (malpractice, same)
Total = ~$183.71 per procedure (facility, GPCI 1.0)

Real-World Range (2025):

Non-Facility (office OR): $200 -$ 250 (depending on GPCI)
Facility-Based (hospital OR, ASC): $170 -$ 210
Commercial Insurance: $1, 200 -$ 3,500 (typically 5-16× Medicare)

GLOBAL PERIOD - CPT 21386

Global Period Status: 090 days (90-Day Global)

What This Means:

CPT 21386 has a 90-day global period (same as 21390)
Includes: Pre-operative assessment, procedure, post-operative visits for 90 days
One flat fee covers all bundled services
No additional payment for routine post-operative management during 90 days
Separate payment only for unrelated E/M services (use modifier -24)

Billing Implications:

Cannot bill separate E/M codes within 90 days for orbital fracture-related care
CAN bill separate E/M code for unrelated issues with modifier -24
Same-day E/M + 21386 can be billed with modifier -25 if separately identifiable

DOCUMENTATION REQUIREMENTS FOR CPT 21386

(Similar to 21390, with emphasis on why implant NOT needed)

Minimum Documentation Components

Pre-Operative Assessment: (See 21390 section for detailed assessment)

Additional Documentation for 21386:

Assessment of Need for 21386 (No Implant) - CRITICAL:

Rationale for Primary Closure Without Implant:

Fracture characteristics support primary closure:
- Small fracture (size documented)
- Minimal comminution (few fragments)
- Minimal volume loss
Good bone healing potential:
- Adequate blood supply
- Clean fracture edges
- No significant patient factors preventing healing
Muscle entrapment assessment:
- Limited entrapment? (can be released)
- Risk of persistent diplopia? (low with this approach)
Enophthalmos risk assessment:
- Minimal risk (documented)
- Not expected to develop with primary closure

Operative/Procedure Documentation:

Fracture Assessment - CRITICAL:

Fracture size: Documented (mm)
Comminution: Minimal or minimal comminution (clean break)
Volume assessment: Minimal volume loss
Bone edges: Sharp, well-approximated? Documented

Reduction:

Herniated contents: Reduced back into orbit
Muscle status: Any entrapment? Released? Movement restored post-reduction?
Hemostasis: Achieved

Closure - KEY DOCUMENTATION:

Decision: Why was implant NOT needed?
Technique: How was fracture closed? (primary closure, bone-to-bone reduction, sutures, etc.)
Result: Fracture well-approximated after primary closure
Eye position: Normal projection restored
Mobility: Full, free eye movements achieved

Post-Operative Assessment & Instructions:

Similar to 21390 (see above)
May emphasize: “Avoid rubbing/straining to protect primary closure as it heals”

BILLING RULES & MODIFIERS - CPT 21386

Common Modifiers

(Same modifiers as 21390)

Modifier	Description	When to Use
-50	Bilateral Procedure	If bilateral fractures repaired same session
-22	Increased Procedural Services	If complexity significantly greater (rarely used with 21386)
-51	Multiple Procedures	If additional procedures performed same session
-52	Reduced Services	If procedure partially reduced
-25	Significant, separately identifiable E/M	If E/M + 21386 same day
-24	Unrelated E/M during postoperative period	If billing E/M for unrelated issue during 90 days
None (most common)	Standard billing	Routine single orbital fracture repair

MEDICARE RULES FOR CPT 21386

(Same as 21390 for most rules - 90-day global period, facility vs non-facility, etc.)

Key Differences from 21390:

1. Implant Cost:

No implant = no separate implant cost
All cost included in surgical fee
Simpler billing (no implant supply codes)

2. Complexity/Modifier -22:

21386 is already “simple” repair, so modifier -22 is rarely appropriate
Only if unusual circumstances made it more complex than typical

3. Payment Difference:

21386 lower RVU (6.67) than 21390 (7.62)
Medicare payment difference ~$30 lower for 21386
Reflects lower complexity and no implant

LOCAL COVERAGE DETERMINATIONS (LCDs) & NATIONAL COVERAGE - CPT 21386

National Coverage Determination (NCD)

There is NO specific NCD for CPT 21386.

General Medicare Coverage Policy:

Orbital floor fracture repair covered when medically necessary
Primary closure repair (21386) covered for appropriate fractures
Documentation must support suitability for primary closure without implant

2025 REIMBURSEMENT INFORMATION - CPT 21386

Medicare 2025 Fee Schedule

Category	Value
Work RVU	4.35
Practice Expense RVU (non-facility)	2.01
Practice Expense RVU (facility)	1.02
Malpractice RVU	0.31
Total RVU (non-facility)	6.67
Total RVU (facility)	5.68
Conversion Factor (2025)	$32.35
National Average Fee (Non-Facility, GPCI 1.0)	$215.86
Estimated Range (Non-Facility)	$200 - 250
National Average Fee (Facility, GPCI 1.0)	$183.71
Estimated Range (Facility)	$170 - 210

Year-Over-Year Comparison (2024 vs 2025)

Metric	2024	2025	Change
Work RVU	4.35	4.35	-
PE RVU (non-facility)	2.01	2.01	-
CF	$33.29	$32.35	-2.83%
National Average (Non-Facility)	~$222.72	~$215.86	-2.83%

Commercial Insurance & Medicaid Reimbursement (2025)

Commercial Insurance:

Typically pays 5-16× Medicare rates
Estimated 21386 payment: $1, 200 -$ 3,500 (slightly less than 21390 due to lower complexity)
Most commercial plans cover orbital fracture repair

Medicaid:

Varies by state
Estimated 21386 payment: $180 -$ 450 (typically below Medicare)
Coverage may require prior authorization

COMPARISON TABLE

Aspect	CPT 92083 (Visual Field)	CPT 21390 (Orbital Fx w/Implant)	CPT 21386 (Orbital Fx w/o Implant)
Specialty	Ophthalmology/Optometry	Oculoplastic/ENT Surgery	Oculoplastic/ENT Surgery
Procedure Type	Diagnostic test	Surgical repair	Surgical repair
Global Period	000 (zero)	090	090
Work RVU	0.60	4.89	4.35
Total RVU (Non-Facility)	0.99	7.62	6.67
Medicare Payment (Non-Facility)	~$32	~$247	~$216
Procedure Time	15-30 min	60-120 min	45-90 min
Common Place of Service	Office	Hospital OR, ASC, Office OR	Hospital OR, ASC, Office OR
Clinical Indication	Glaucoma monitoring, neurologic defects, screening	Orbital floor fracture with significant defect	Orbital floor fracture, uncomplicated
Complexity	Low	High	Moderate-High
Anesthesia	Topical/local	General	General
Key Findings Documented	Visual field defects, reliability indices, interpretation	Fracture characteristics, muscle involvement, implant type	Fracture characteristics, reason for no implant
Reimbursement Frequency	Annual (stable) or more (progressive)	One-time procedure	One-time procedure

Commercial Payment | $50 -$ 200 | $1, 500 -$ 4,000 | $1, 200 -$ 3,500 |

CPT 21386 FAQs:

Q: When should I use 21386 instead of 21390?
A: 21386 for small, uncomplicated fractures with primary bone-to-bone closure possible. 21390 for large defects, significant comminution, or volume loss requiring implant support.

Q: Can a patient with 21386 need later conversion to implant repair?
A: Possible if primary closure fails or patient develops enophthalmos/diplopia over time. Revision would be separate procedure/billing. Document if this is a revision case.

Q: How do I document why implant wasn’t needed?
A: In operative note: “Fracture small (<1cm), minimal comminution, good bone edges suitable for primary closure. Minimal volume loss. After reduction and closure, eye position normal and motility full—no implant needed.”

Scenario 3: CPT 21386 - Simple Orbital Fracture, Primary Closure

Patient: 45-year-old with small orbital floor fracture from fall

Clinical Assessment:

Fall from ladder, struck eye on edge
CT: Small right orbital floor fracture, <1cm, minimal comminution
Minimal orbital contents herniated
Mild enophthalmos (1-2mm)
Diplopia improving with time
Small defect suitable for primary closure

Procedure:

General anesthesia
Periorbital incision
Fracture site reduced
Small orbital floor defect (8-10mm)
After reduction: fracture edges well-opposed; no gap
No implant needed—primary bone-to-bone closure sufficient
Conjunctival wound closed
Eye position good; motility full

CPT 21386 (Orbital Fracture, Primary Closure)

Code type: Surgical repair
RVU: 4.35 work; 6.67 total (non-facility)
Medicare payment: ~$216 (non-facility)
Global period: 090 days
Key documentation: Operative report, imaging (CT), fracture characteristics, reason for no implant
Common modifiers: -50 (bilateral), -25 (trauma E/M)
Audit risk: Low-Moderate (ensure documentation supports decision for primary closure vs implant)

Document Created: February 2026
Compliant with: 2025 Medicare Physician Fee Schedule, CMS National and Local Coverage Determinations
Last Updated: February 2026

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