How To Use CPT Code 21395

CPT 21395 describes the open treatment of an orbital floor blowout fracture using a periorbital approach with bone graft. 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 21395?

CPT 21395 is used to describe the open treatment of an orbital floor blowout fracture using a periorbital approach with bone graft. This procedure is performed to restore function and appearance to the face after a blowout fracture, which is caused by blunt force trauma. The provider accesses the orbital floor through a skin incision over the fracture area and applies bone graft material taken from the patient’s own body to fill in bony defects at the fracture site.

2. Official Description

The official description of CPT code 21395 is: ‘Open treatment of orbital floor blowout fracture periorbital approach with bone graft (includes obtaining graft).’

3. Procedure

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 to access the floor of the orbit.
5. The provider dissects through the tissue to the floor of the orbit to define the margins of the fracture.
6. A scalp incision is made to harvest a cranial bone graft.
7. The provider incises the outer table of the skull and acquires cortical bone graft material.
8. The graft material is shaped to fit the defects in the orbital bones.
9. The bone grafts are secured in place with screws or wires.
10. The wound is irrigated, corneal shields and traction sutures are removed, and all incisions are closed.

4. Qualifying circumstances

CPT 21395 is performed on patients with a blowout fracture of the orbital floor, which is caused by blunt force trauma. The procedure is intended to restore function and appearance to the face. The patient must have bony defects at the fracture site that can be filled with a bone graft. The provider must use a periorbital approach and obtain the bone graft material from the patient’s own body.

5. When to use CPT code 21395

CPT code 21395 should be used when the provider performs an open treatment of an orbital floor blowout fracture using a periorbital approach with bone graft. This code is appropriate when the procedure involves obtaining the bone graft material from the patient’s own body. It should not be used for other types of orbital floor fracture treatments or when bone graft material from an external source is used.

6. Documentation requirements

To support a claim for CPT 21395, the provider must document the following information:

• Patient’s diagnosis of a blowout fracture of the orbital floor
• Details of the procedure, including the periorbital approach and the use of bone graft material obtained from the patient’s own body
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 21395, ensure that the procedure meets the criteria for an open treatment of an orbital floor blowout fracture using a periorbital approach with bone graft. The bone graft material must be obtained from the patient’s own body. There are no specific guidelines regarding reporting CPT 21395 with other codes.

8. Historical information

CPT 21395 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

1. A patient with a blowout fracture of the orbital floor undergoes open treatment using a periorbital approach with bone graft.
2. A provider performs an open treatment of an orbital floor blowout fracture, obtaining bone graft material from the patient’s own body.
3. A blowout fracture of the orbital floor is repaired using a periorbital approach with bone graft, restoring function and appearance to the patient’s face.
4. An individual with a blowout fracture of the orbital floor undergoes open treatment, with the provider using a periorbital approach and bone graft material obtained from the patient’s own body.
5. A provider performs an open treatment of an orbital floor blowout fracture, using a periorbital approach and bone graft material taken from the patient’s own body to fill in bony defects.
6. A patient with a blowout fracture of the orbital floor receives open treatment, with the provider accessing the orbital floor through a periorbital approach and using bone graft material obtained from the patient’s own body.
7. An open treatment is performed on a blowout fracture of the orbital floor, utilizing a periorbital approach and bone graft material taken from the patient’s own body.
8. A provider repairs a blowout fracture of the orbital floor using a periorbital approach and bone graft material obtained from the patient’s own body.
9. An individual undergoes open treatment for a blowout fracture of the orbital floor, with the provider using a periorbital approach and bone graft material taken from the patient’s own body.
10. A blowout fracture of the orbital floor is repaired through open treatment, with the provider utilizing a periorbital approach and bone graft material obtained from the patient’s own body.