How To Use CPT Code 21408

CPT code 21408 describes the open treatment of a fracture of the orbit, excluding blowout fractures, with bone grafting. 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 21408?

CPT 21408 is used to describe the open treatment of a fracture of the orbit, specifically excluding blowout fractures, with the use of bone grafting. This code is used when a provider performs a surgical procedure to treat a fracture of the bony structure that holds the eyes, typically resulting from blunt force trauma. The procedure involves making an incision over the fracture, realigning the fractured bones, and stabilizing the area with bone graft material.

2. Official Description

The official description of CPT code 21408 is: ‘Open treatment of fracture of orbit, except blowout with bone grafting (includes obtaining graft).’ This code specifically excludes blowout fractures, which involve the walls of the orbit being blown out due to the force of the trauma.

3. Procedure

The procedure for CPT code 21408 involves several steps:

1. The patient is appropriately prepped and anesthetized.
2. The provider makes an incision over the site chosen for harvesting a bone graft, typically from the hip bone.
3. Sufficient autograft, which is tissue graft harvested from another location in the patient’s own body, is removed and the wound is closed.
4. The provider then makes an incision over the area of the fracture and dissects through the tissue to visualize the fractured orbit.
5. Using surgical tools, the provider reduces, or realigns, the fractured bones back into their normal positioning.
6. Bone graft material is placed to fill in any defects and stabilize the bone.
7. Screws or wires may be used to ensure that the graft does not migrate.
8. The provider irrigates the area, checks for bleeding, removes any instruments, and closes the incision.

4. Qualifying circumstances

CPT 21408 is used for the treatment of fractures of the orbit, excluding blowout fractures. The procedure involves the use of bone grafting to stabilize the area. It is typically performed in cases where there is a fracture resulting from blunt force trauma. The patient must meet the criteria for the specific fracture and bone grafting procedure, and the provider must document the necessity of the treatment.

5. When to use CPT code 21408

CPT code 21408 should be used when a provider performs an open treatment of a fracture of the orbit, excluding blowout fractures, with bone grafting. It is important to note that this code specifically excludes blowout fractures, which involve the walls of the orbit being blown out due to the force of the trauma. If the procedure does not involve bone grafting or if it is a blowout fracture, a different CPT code should be used.

6. Documentation requirements

To support a claim for CPT 21408, the provider must document the following information:

• Patient’s diagnosis and the need for open treatment of a fracture of the orbit
• Specific details of the procedure, including the incision site for bone graft harvesting
• Date of the procedure
• Details of the fracture reduction and bone grafting process
• Use of screws or wires, if applicable
• Confirmation of irrigation, absence of bleeding, removal of instruments, and closure of the incision

7. Billing guidelines

When billing for CPT 21408, ensure that the procedure meets the criteria for open treatment of a fracture of the orbit, excluding blowout fractures, with bone grafting. It is important to accurately document the procedure and use the appropriate CPT code. Additionally, follow any specific billing guidelines provided by the payer or insurance company.

8. Historical information

CPT 21408 was added to the Current Procedural Terminology system on January 1, 1993. There have been no updates to the code since its addition.

9. Similar codes to CPT 21408

There are several similar codes to CPT 21408 that may be used in different circumstances. These include:

• CPT 21410: Open treatment of fracture of orbit, except blowout; with exploration and repair of orbital floor fracture
• CPT 21421: Open treatment of fracture of orbit, except blowout; with exploration and repair of orbital roof fracture
• CPT 21431: Open treatment of fracture of orbit, except blowout; with exploration and repair of orbital rim fracture
• CPT 21440: Open treatment of zygomatic fracture, except isolated zygomatic arch fracture, with elevation of zygomatic complex
• CPT 21445: Open treatment of zygomatic fracture, except isolated zygomatic arch fracture, with elevation of zygomatic complex and fixation

9. Examples

1. A patient sustains a fracture of the orbit due to a car accident. The provider performs an open treatment of the fracture, excluding blowout, with bone grafting to stabilize the area.
2. An individual is involved in a physical altercation and suffers a fracture of the orbit. The provider performs an open treatment of the fracture, excluding blowout, with bone grafting to realign the fractured bones.
3. A patient falls and fractures their orbit. The provider performs an open treatment of the fracture, excluding blowout, with bone grafting to ensure proper healing and stability.
4. During a sporting event, a player is hit in the face and sustains a fracture of the orbit. The provider performs an open treatment of the fracture, excluding blowout, with bone grafting to repair the damage.
5. An individual is involved in a workplace accident and suffers a fracture of the orbit. The provider performs an open treatment of the fracture, excluding blowout, with bone grafting to restore normal positioning of the bones.
6. A patient is assaulted and sustains a fracture of the orbit. The provider performs an open treatment of the fracture, excluding blowout, with bone grafting to stabilize the area and promote proper healing.