How To Use CPT Code 21386

CPT 21386 describes the open treatment of an orbital floor blowout fracture using a periorbital approach. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 21386?

CPT 21386 is used to describe the open treatment of an orbital floor blowout fracture using a periorbital approach. This procedure is performed by a healthcare provider to repair the floor of the orbit, which is the bony structure that holds the eyes. The goal of this treatment is to restore function and appearance to the face after a blowout fracture, which is caused by blunt force trauma.

2. Official Description

The official description of CPT code 21386 is: ‘Open treatment of orbital floor blowout fracture periorbital approach.’

3. Procedure

The procedure for CPT 21386 involves several steps:

1. The patient is appropriately prepped and anesthetized.
2. Corneal shields are inserted to protect the eyes.
3. Traction sutures are placed on the lower eyelids to hold them open.
4. A transconjunctival incision is made.
5. The healthcare provider dissects through the tissue to the floor of the orbit to define the margins of the fracture.
6. Using surgical tools, the provider reduces, or realigns, the fracture.
7. The wound is irrigated.
8. The corneal shields and traction sutures are removed.
9. The incisions are closed.

4. Qualifying circumstances

CPT 21386 is performed on patients who have a blowout fracture of the orbital floor, which is caused by blunt force trauma. This procedure is used to restore function and appearance to the face. It is important to note that this code specifically refers to the periorbital approach, which involves accessing the orbital floor through an incision over the fracture area.

5. When to use CPT code 21386

CPT code 21386 should be used when a healthcare provider performs an open treatment of an orbital floor blowout fracture using a periorbital approach. This code is appropriate when the provider repairs the floor of the orbit to restore function and appearance to the face after a blowout fracture.

6. Documentation requirements

To support a claim for CPT 21386, the healthcare provider must document the following information:

• Patient’s diagnosis of a blowout fracture of the orbital floor
• Description of the periorbital approach used
• Date of the procedure
• Details of the procedure, including any specific techniques or tools used
• Any complications or unexpected findings during the procedure
• Post-procedure instructions or recommendations
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT 21386, ensure that the procedure performed matches the description of the code. The provider should use the periorbital approach to repair the orbital floor blowout fracture. It is important to follow any specific guidelines or requirements from the payer regarding documentation and billing for this procedure.

8. Historical information

CPT 21386 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

Here are some examples of cases where CPT code 21386 may be used:

1. A patient sustains a blowout fracture of the orbital floor due to a sports-related injury. The healthcare provider performs an open treatment using a periorbital approach to repair the fracture and restore function to the patient’s face.
2. An individual is involved in a car accident and experiences a blowout fracture of the orbital floor. The healthcare provider performs an open treatment using a periorbital approach to repair the fracture and improve the patient’s appearance.
3. A patient presents with a blowout fracture of the orbital floor resulting from a fall. The healthcare provider performs an open treatment using a periorbital approach to repair the fracture and restore the patient’s ability to move their eyes properly.
4. During a physical altercation, a person sustains a blowout fracture of the orbital floor. The healthcare provider performs an open treatment using a periorbital approach to repair the fracture and alleviate any associated pain or discomfort.
5. A patient is involved in a workplace accident that causes a blowout fracture of the orbital floor. The healthcare provider performs an open treatment using a periorbital approach to repair the fracture and prevent any further complications.