2025 CPT code 21355
(Active) Effective Date: N/A Revision Date: N/A Surgery - Fracture Treatment Musculoskeletal System Feed
Percutaneous treatment of malar area fracture, including zygomatic arch and malar tripod, with manipulation.
Modifiers may be applicable, depending on the specific circumstances of the procedure. For example, modifier 51 (multiple procedures) may be added if multiple procedures are performed during the same session.Modifier 76 (repeat procedure by the same physician) if the same procedure is repeated by the same physician.
Medical necessity for this procedure is established when the fracture causes significant functional impairment, cosmetic deformity, or risk of complications such as nerve damage or entrapment. The decision to perform percutaneous reduction will depend on the extent and type of fracture and the surgeon's assessment.
The clinical responsibility for this procedure includes pre-operative assessment, planning the surgical approach, performing the percutaneous reduction of the fracture, and post-operative care, including monitoring for complications such as infection, malunion, or nonunion. The surgeon will also manage pain and ensure proper wound healing.If additional procedures are necessary, these will also fall under the surgeon's responsibility.
- Musculoskeletal System
- Surgery > Surgical Procedures on the Musculoskeletal System > Fracture Treatment
In simple words: The doctor repairs a broken cheekbone (malar area) through tiny puncture incisions.They use special tools to carefully move the bone fragments back into the correct position.
This CPT code, 21355, describes percutaneous treatment of a fracture in the malar region, encompassing the zygomatic arch and malar tripod, which involves manipulation to restore proper bone alignment.The procedure is performed through small puncture incisions, avoiding extensive surgical exposure. Manipulation is used to reposition the fractured bone fragments. The procedure may include the use of image guidance techniques.
Example 1: A patient presents after a motor vehicle accident with a depressed zygomatic fracture. The surgeon performs a percutaneous reduction and manipulation under fluoroscopic guidance to restore the bone anatomy., A patient sustains a malar fracture during a sporting event.The fracture is minimally displaced.The surgeon performs a percutaneous reduction and manipulation to correct the alignment., A patient with a complex malar fracture involving multiple fragments and significant displacement undergoes a percutaneous reduction and manipulation with the assistance of image guidance (fluoroscopy) to achieve precise anatomical repositioning.
Detailed pre-operative and post-operative notes, including imaging studies (X-rays, CT scans) demonstrating the fracture, operative report detailing the procedure, including the approach, manipulation techniques used and any complications encountered.Follow-up notes documenting the patient's progress and any additional treatment required.
** This procedure may require the use of specialized instruments and imaging guidance (fluoroscopy) to ensure accurate reduction of the fracture. The surgeon's judgment is critical in determining the most appropriate approach and treatment strategy for each individual case.
- Payment Status: Active
- Modifier TC rule: A technical component (TC) modifier is not typically applicable to this code since it is a surgical procedure performed by the physician.
- Specialties:Oral and Maxillofacial Surgery, Plastic Surgery
- Place of Service:Office, Ambulatory Surgical Center, Hospital Outpatient