2025 CPT code 21811

Open treatment of rib fracture(s) with internal fixation, includes thoracoscopic visualization when performed, unilateral; 1-3 ribs.

Do not report imaging guidance separately. Casting, splinting, or strapping for temporary stabilization is not coded as closed treatment. Do not separately report external fixation when listed in the code descriptor.

Modifiers applicable to this code include 22 (Increased Procedural Services), 50 (Bilateral Procedure), 52 (Reduced Services), 53 (Discontinued Procedure), 58 (Staged or Related Procedure or Service), 59 (Distinct Procedural Service), 76 (Repeat Procedure by Same Physician), 77 (Repeat Procedure by Another Physician), 78 (Return to the Operating Room), 79 (Unrelated Procedure), 80 (Assistant Surgeon), 81 (Minimum Assistant Surgeon), and 82 (Assistant Surgeon when qualified resident surgeon not available).

Medical necessity for this procedure is established by documentation of displaced, unstable, or non-union rib fractures causing significant pain, impaired respiratory function, or other complications.

The surgeon prepares the patient and administers anesthesia.An incision is made over the fractured rib(s). The surgeon then realigns the broken bones and uses internal fixation devices to stabilize the fracture(s). The area is then cleaned, bleeding is controlled, and the incision is closed.

IMPORTANT For bilateral procedure, report 21811 with modifier 50. For 4-6 ribs use 21812, and for 7 or more ribs use 21813.

In simple words: This procedure treats broken ribs through surgery. The surgeon makes an incision to access the broken rib(s), realigns the bones, and uses hardware like plates and screws to hold them in place.A tiny camera might be used to see inside the chest during the procedure. This code covers the treatment of one to three ribs on one side of the body.

Open treatment of one to three rib fractures with internal fixation. This includes thoracoscopic visualization when performed, on one side of the body.Internal fixation involves the use of hardware like plates, screws, nails, and wires to stabilize the fracture.

Example 1: A patient sustained two broken ribs on their right side in a car accident. The fractures are displaced and require open reduction and internal fixation using plates and screws., A patient fell off a ladder and fractured three ribs on their left side. The fractures are unstable and require surgical intervention with internal fixation., A patient with a previous rib fracture experiences non-union of the bone, requiring open treatment with internal fixation for proper healing.

Documentation should include details of the injury, imaging reports confirming the fracture(s), type of internal fixation used, and operative report detailing the procedure performed. The number of ribs repaired and laterality (right or left) must be clearly documented. Thoracoscopic visualization, if performed, should also be documented.

  • Revenue Code: P3D - MAJOR PROCEDURE, ORTHOPEDIC - OTHER
  • Global Days : Global Days: 90
  • Payment Status: Active
  • Specialties:Thoracic Surgery, Orthopedic Surgery
  • Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center
** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.