Need help choosing the right code?
Ask CasePilot about procedures, modifiers, bundling, and coding guidance.
Try CasePilot© Copyright 2026 American Medical Association. All rights reserved.
The CPT® Code 21406 refers to the open treatment of a fracture of the orbit, specifically excluding blowout fractures, and is performed without the use of an implant. This procedure is designed to restore the natural shape of the orbit, which is the bony cavity that houses the eye. In cases of orbital fractures, the integrity of the orbit can be compromised, leading to potential complications such as misalignment of the eye, double vision, or damage to surrounding structures. The open repair technique involves making an incision to access the fractured area directly, allowing for precise manipulation and correction of the fracture. The procedure may also include the use of a temporary tarsorrhaphy, which is a technique to protect the cornea by suturing the eyelids partially closed. This is particularly important during the initial stages of the procedure to prevent exposure and injury to the eye. The surgical approach requires careful dissection to preserve the surrounding tissues and nerves, ensuring that the repair is both effective and minimizes the risk of complications. Overall, the goal of this procedure is to restore the anatomical and functional integrity of the orbit, thereby improving the patient's visual and cosmetic outcomes.
© Copyright 2026 Coding Ahead. All rights reserved.
The open treatment of an orbital fracture, as described by CPT® Code 21406, is indicated for specific conditions related to the integrity of the orbit. These indications include:
The procedure for the open treatment of an orbital fracture involves several detailed steps, which are as follows:
After the completion of the open treatment for an orbital fracture, specific post-procedure care is essential for optimal recovery. Patients are typically monitored for any signs of complications, such as infection or excessive swelling. Pain management may be provided as needed, and patients are advised to avoid activities that could strain the eye or the surgical site. Follow-up appointments are crucial to assess healing and ensure that the eye is functioning properly. Patients may also receive instructions regarding the care of the incision site to promote healing and minimize scarring. Overall, the recovery process will vary depending on the individual case and the extent of the fracture.
| Short Descr | OPN TX ORBIT FX W/O IMPLANT | Medium Descr | OPEN TX FX ORBIT EXCEPT BLOWOUT W/O IMPLANT | Long Descr | Open treatment of fracture of orbit, except blowout; without implant | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 1 - 150% payment adjustment for bilateral procedures applies. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 2 - Payment restriction for assistants at surgery does not apply to this procedure... | Co-Surgeons (62) | 1 - Co-surgeons could be paid, though supporting documentation is required... | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Hospital Part B services paid through a comprehensive APC | ASC Payment Indicator | Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight. | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P3D - Major procedure, orthopedic - other | MUE | 1 | CCS Clinical Classification | 144 - Treatment, facial fracture or dislocation |
| 50 | Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AG | Primary physician | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | ET | Emergency services | GC | This service has been performed in part by a resident under the direction of a teaching physician | LT | Left side (used to identify procedures performed on the left side of the body) | RT | Right side (used to identify procedures performed on the right side of the body) |
|
Date
|
Action
|
Notes
|
|---|---|---|
| 2013-01-01 | Changed | Short Descriptor changed. |
| Pre-1990 | Added | Code added. |
Get instant expert-level medical coding assistance.